Christmas eve dscharges

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Everyone of those bulleted names needed to be discharged.

Merry Christmas and Happy New Year everyone!

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Overlook, discharge and admission

1. Overlook

Last week I missed an important blood result in one of our seriously ill patient which indicated that the patient might have had a heart attack. I was taking blood for our patient in another ward when a staff nurse told me that my ward called me back as prof was doing her rounds (she does come randomly and unpredictably). I quickly settled that and went back. Just as I joined the round, my MO then asked me in an alarmed tone ‘why didn’t you informed us that that patient’s trop-t was raised?’ In a reflex to defend myself, I said I did and said I dismissed it because it may raised due to the patient’s underlying chronic kidney disease. But on second thought, I really cannot recall noticing that particular result. The patient was already on day 2 of admission and has been treated for sepsis and respiratory failure and the team was concentrating on the inflammatory markers (WCC, CRP) and the ABG. Only on that day that they have noticed the raised Trop-T and treated the patient for a possible heart attack. Prof told me off for not realizing and informing the team about it. I was not the only one who has seen the patient. The blood was taken when the patient was admitted – the oncall HO, MO, registrar would have seen it; prof, my registrar, my MO and myself have seen the patient on the day before, so why do I feel like I alone have to take full responsibly and the blame for everything? In the past, an MO had told me to really be careful to double check every clinical decisions with our seniors or other specialty as there is a strong blame culture in this hospital, and I finally had a taste of it. Fair enough, I have overlooked it, but I’m not the only one who is in charged of the patient. Still doesn’t stop me from feeling bad – what if the patient has really had a heart attack? Anyway cardio came to review the patient and also thought that the raised Trop-T was due to the underlying kidney disease and there’s no heart attack. Relieved.

2. Discharge and admission robot

On average, we have about 4 discharges per day, shared between two of us (Debbie and I the house officers). On Friday as it was Christmas eve, Debbie took leave (which our specialist, registrar, MO and I had to sign to approve – what a task!), and my seniors decided to go crazy with discharges - 13 patients all together. 13! That's clearing half the ward!

My record before this was 9 discharges on my first week of work, then the team was nice enough that the specialist, registrars and MOs helped me out with a few. My personal discharge that I've done myself was 7. Yesterday, without Debbie around, I was completely overwhelmed. There were 2 registrars and 2 MOs, but they all disappeared after the ward round. I know we have patients at other places to see (ICU, HDW (High dependency) etc but only a few, 3 patients I think) but I was hoping that at least one of the MOs would stay behind to help do some of the post-round referrals, phone calls while I do the blood taking, prescribe, fill in forms and other small jobs. Nop. I had to do everything myself. Started discharge at 3:30pm. Then my MO did a pleural tap, and threw all the samples for me and asked me to label and send them of and do some more bloods (WTH!!! When I’m stressed even small things like this can wind me up. Staff nurse ended up helping me – I love her). Did not stop at all, finished last discharge at 9:30pm. Dreaded to think that I was also oncall after. By then, already 3 new admission and numerous cannula and blood waiting for me to do. Settled everything by 5am. Had a quick lie in until 6am. Two new unstable admissions came in. Settled those by 7:30am. Went to HDW to do the morning bloods but did not do the usual morning bloods in my ward. No time to shower or wash up, did not eat but couldn’t care less. Continued with ward round, then take the routine bloods during lunch time (which was supposed to have been done before the round). Had something to eat (which my mum so kindly brought in the day before), (forced to) made a ridiculous request for an US guided pleural tapping (which was supposed to have been done my MO but she wanted to go back home), then hid in the seminar room to sleep for half an hour. Sigh… trying very hard not to be angry with my MO because she is very nice and very hardworking and is pregnant and would not have any maternity leave after because she’s a masters student (not allowed to interrupt her studies) and she has been covering the ward alone for a few weeks now (the other MO cannot because she hasn’t got her MMC registration and cannot write or sign anything in documents, nor do any procedures), but I do feel being taken advantage of and get the blame for everything. Staff nurse said on discharge day my face was red and admission day my face was white. Reviewed all the bloods I’ve taken then went back home at 5pm. Totally drained. Called Debbie to pass over and de-stress. Messeged prof to rant. ‘Well done!’ she replied. Robot is flat and today is strictly for recharge only.

Relatives and patients: please note that discharge and speaking about progress on condition, in the doctor’s book, is not urgent. We do have lives to save and I am sorry if you have to wait two hours to speak to the doctor, or until 10pm to be discharged.

Signing off. Recharging continues.

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Work pictures

Debbie, me and my ex-registrar (Dr Yusniza)

Pink day - students, me, Aida, Yusniza, Dr Rosmadi (my ex-registrar - standing in the middle without whitecoat) and Dr Andrea (my ex-specialist - petite one standing next to Rosmadi on the right)

Me, my ex-MO (Dr Aida) and my ex-registar (Dr Megat)

Blue day - students, me, Aida, Megat and Andrea

Oncall room

Me at work and post-call (can you feel my exhaustion?)

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Surviving house jobs - excerpt from the bible

If some fool or visionary were to say that our aim should be to produce the greatest health and happiness for the greatest number of our patients, we would not expect to hear the greatest cheering from the midnight house officers: rather, our ears are detecting a decimated groan - because these men and women know that there is something at stake in house-officership far more elemental than health or happiness: namely survival. Here we are talking about our own survival, not that of our patients. It is hard to think of a greater peacetime challenge than these first few months in the wards. Within the first weeks, however brightly your armour shone, it will be smeared and splattered if not with blood, then with the fallout from very many decisions which were taken without sufficient care and attention. Not that you were lazy, but force majeure on the part of Nature and the exigencies of ward life have, we are suddenly stunned to realize, taught us to be second rate: for to insist on being first-rate in all areas is to sign a kind of death warrant for many of our patients, and more pertinently for this page, for ourselves. Perfectionism cannot survive in the clinical world. To cope with this fact, or, to put it less depressingly, to flourish in this new world, don't keep re-polishing your armour, rather, furnish your mind and nourish your body. Do not voluntarily deprive yourself the restorative power of sleep. A good nap is the order of the day - and for the nights, sleep for as long as possible. Remember that sleep is our natural state in which we were first created, and we only wake to feed our dreams.

Copied from the Oxford Handbook of Clinical Medicine, 7th edition.

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I dread

I'm not bad at blood taking and cannulation, so I do get called a lot to help out especially with difficult ones. But who knows my hidden hatred for such patients? The sorts of patients that i hate are: 

1. Nephro - cannot use one hand because needed for AVF formation; needs blood taking daily to monitor renal function and VBG, stays in hospital for ages because they just don't get better. Worst ones are when AVF failed on one hand already, another hand not allowed to use, leg veins already ruined by other house officers - how and what do you want me to do?

2. Obesity - Obese patients should be barred from coming into hospital. Do you have any idea how difficult it is to see or do anything through those thick subcutaneous tissue? Same applies to oedematous patients.

3. Relative - who refuses to go out, who peeps through the curtain when I specifically asked you to go out and wait faraway. Yes, torture session of your grandmother in progress and I don't think you would derive any pleasure from seeing me poke her for 10 times and I asked you to go away for good reason.  

4. Patient - who tries to be helpful by moving around, thinking that they are smarter than me, who demands for left leg instead of right when I have another 5 new patients to clerk in, who kicks and jumps, who has ridiculously low pain threshold, who moans and groans non-stop when I am doing you a service and trying to save your life (be informed that any plea, prayer or piss would not stop me from doing what I do, which is usually to persist until I get it, even if I have to poke you 20 times). 

I value my relationship with my colleagues. I try my best to be a good team player. I am usually willing to help out with anything whenever I can, but doesn't mean that I don't dread it. But sometimes I wish I'm not, so someone else can be called to help, because I am spending ages to deal with these difficult bloods. A difficult cannulation will take at least 20 minutes and I'd much rather be doing something else. As well as a pair of good hands, I think I have good brains as well and I'd like to use it more often rather than just spending so much time picking up other people's mess.

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Throwing in the towel

Yesterday was one of the worst days since I have started working.

 

On call the night before was not particularly heavy. But one of the new patients had a seizure requiring urgent CT brain, and another was vomiting and bleeding fresh blood (with other issues like extremely difficult vein and relatives who refused to let me poke her to save her lives. Acutely ill patients like this takes up a lot of my time and energy, leaving less for the rest of the jobs. As well as that, I had to deal with two of my usual patients in my ward – one wanted to discharge himself and another wanted me to write letter of a summary of his condition for financial help (which was not urgent in my book, can wait). Also at the beginning of the oncall, no one could contact the other HO – so I ended up doing several jobs for him as well. I did finally get a chance to have my dinner at 3:30am. My last 3 admissions arrived after 5am. Usually if I am still having lots of unsettled jobs by 6am I start to panic because it is my experience that if I don’t start my usual ward job by 6:30am, everything will be delayed in the day. After clerking the last patient at 7am, high dependency (HDW) started calling to ask me to take blood. I only finished the new patient clerking by 7am. Imagine the shock when they tell me that I have to take blood from all of the patients there. HDW patients’ bloods are not easy to take as they are usually very sick. I was still doing bloods there at 8am. Really really stressed up then thinking that I still have to shower, morning bloods at wad warga and 2 hours late for my ward work, and I just couldn’t hold back my tears and snouts while actually poking a needle in the patient. Luckily Debbie and the medical students were super efficient that morning to have finished all the bloods by the time I arrived. Such is the usual arrangement that the oncall person has to do the morning bloods for HDW and wad warga (as well as CCU, CRW sometimes) as they don’t have house officer there and I feel really being taken advantage of. Do they not realize on normal days we have to start our regular morning blood taking as early as 6:30am to avoid running behind?   

 

Prof was in a bad mood yesterday. Everyone got some bullets from her, from the medical student right up to the registrar. Even I was unusually alert (normally I am half asleep in rounds post-call). So many new patients. My registrar was amazing and helped me out and didn’t take forever to review the patients. One of the patients was from Debbie’s side – so many things not done – so I had to pick up the pieces and answer when prof and the other specialist demanded to know why things were not done. Usually my MO follows round on my side but she left half way today – so I had to be totally in charged of all the jobs for the patients on my side.   

 

Half way during the round, a nurse from the other ward called me. In a very fierce tone, she demanded to know why had I not prescribed the medication for a patient admitted last night. Really? When she told me the name, it didn’t even ring a bell. I left the ward round and went down to that ward anyway. The specialist in that ward started questioning why have I not clerked the patient, and the nurse started asking if I’ve not clerked the patient who was it who wrote in the notes? Looked at the notes – no one clerked the patient; in fact the nurse did not inform me that patient had been admitted. They called the nurse on duty the night before – indeed she admitted to have forgotten to call the on-call doctor to clerk the patient in. OK. Scolded for nothing of my fault, but nevermind. I hate nurses in this ward.   

During round also, the patient from the night before who wanted the letter for social welfare became really angry and shouting around saying that I have not given him what he wanted. The registrar kindly sorted out the problem for me, and the patient apologized (all very civilized after), but still didn’t stop me from feeling very incompetent and that all was my fault. 

 

Then in the evening I was doing a discharge at the other ward, Debbie called me and spoke to me and Mandarin, asking if I have made a referral to gastro, which I did, and said the MO told me to come back here immediately because he was very angry. I rolled my eyes. OK OK I made a late referral. Nevermind there was a 2 hour Friday prayer break, nevermind that I was given passed around 3 people before being passed to the right gastro person for referral, nevermind that I had 1000 other more urgent jobs to do including helping Debbie with an extremely difficult blooding taking, nevermind that whenever I tried to do referrals nurses or some other people would snatch the patient file away from me, nevermind that the phone is constantly being used. It’s my wrong. Always. Stressed out, I cried again. I told the nurses my eyes were red only because I was tired.     

 

Looking after 12 patients (from yesterday 16) may sound easy. Sometimes, but usually not. There are always so ill that they shouldn’t have been in the general ward. A patient on BIPAP (breathing support) needs bloods every few hours. There was once when three doctors were spending 3 hours inserting an IV on one patient. Do you know how much work could have been done by 3 doctors in 3 hours for the rest of the 27 patients? As houseman we are the ones responsible for the unpleasant job for poking people, and I just get so much complaints and abuse every time I approach some of these patients. It is not me who want to poke, I am nothing but a slave. And because I am around all the time, relative comes to me to discuss about the patient just when I am rushing to finish through all my discharges. And nurses would call you to ask about insulin doses, prescribe drugs, do IV lines, see acutely ill patient etc etc. I know it is important to know the progress of the patient for the relative and attend to ill patients, but it is even more important that I get through my 7 discharges this evening without interruption.  

 

So yesterday was a really bad day. I went home at 11pm (40 continuous working hour in hospital) and still there were 4 referrals not done, one phone enquiry not done, many forms not filled in, 2 blood cultures not taken etc etc. Patients are staying in hospital unnecessarily long because the houseman is too incompetent to sort out all the jobs in time – and I do deserve to be told off sometimes. Making referrals and requesting for radiological scans especially, we needed to be very clear of the patient history and progress, and know exactly why we are referring a patient and have the necessary investigation – trouble is I don’t always know. The workload is so heavy that I needed to work at bullet pace. There is no time to think or discuss why things are happening or needed to be done, no time to read or check things up. That’s why I’m still so blur with regards to the management of common medical conditions. I have been working for 6 weeks now and I am still so unorganized – I really doubt that I would ever be up for the job.

 

It is nice when my senior says things like ‘Of course she’s good, she’s my houseman’. Yesterday a sister said ‘O… you are Dr Tan. One of the senior doctors said you are very good’, and I told her ‘OK. But I don’t really care.’ Now I have started not to believe people when they tell me I am doing a good job or anything like that. I don’t want to be complacent even for a bit. Can’t afford to because I know I am not.

 

Now my parents are also angry at me because I am leaving home earlier and earlier and going back home later and later everyday. And they get upset if I tell them that I haven’t been to the toilet all day or haven’t eaten anything all day (especially when oncall, can go by without lunch, dinner, breakfast and lunch on the next day). So, I avoid telling them anything of this sort now. It is physically and emotionally draining to be parents of houseman.

 

Stages of bereavement: Denial – Anger –Bargaining – Depression – Acceptance  

I am still at the denial stage.

 

Finally learnt how to apply for leave yesterday. Might get a day off or two soon.

 

 

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A House Officer in a Teaching Hospital: Week 2

Monday

Don't remember what happened on Monday. Probably nothing significant. A group of 10 final year medical students came to join us in the ward. Their job is to make me happy. I am their boss. I am so grateful they are here. Dr Andrea gave me a pen and a notebook (to write down my jobs) - that's very nice of her and I am grateful for the presents (hope I won't lose them because of the past few days I nearly had).

Monday night to Tuesday morning I was oncall. It was horrible. Luckily the two MOs were kind enough to help me out. I was so slow to do everything. Bloods that needed to be taken, cannulas that were to be inserted, patients that needed to be clerked in were only done, on average, two hours after they were supposed to be done. One major delaying factor was that I had to go down to MR scan 3 times to sedate this lady, which was a scary experience on its own. When clerking patients, it's such a pain when you cannot read the previous person's clerking, and having to ask around the nurses. The nurses... what shall I say... were just not being supportive during the night. I felt so useless not knowing how to manage anything and having to phone my MO for everything. Call call call coming non-stop. The lady gaga ringtone of my phone got more and more irritating as the night went, and I thought for a few moments that I was having auditory hallucination of the sweet romance ringtone. I need to revise my medical emergencies management and learn how to priorities better.

Tuesday

I was so tired post call that all I could think was can I please go to sleep stat? All I could recall was a really long teaching ward round which lasted until 3pm. The peak of my sleepiness came about during the discussion of renal tubular acidosis in a young patient. I don't care how interesting the physiology of the disease is. I want to get this over with and go home and sleep. I ended up doing discharges until 11pm that night. Working continuously for 42 hours in hospital. Can you imagine my exhaustion?  

Wednesday

I made a patient cry today because I have poked her too many times for ABG. I really cannot understand - this is the second patient that I have encountered that I just simply cannot get any ABG. I did it the usual way which I can proudly say, yield rather good success rate. I tried for about 10x before giving up.

I suddenly had a sense of how meaningful my job is. There's this patient whom I really wish not see everyday. He has chronic renal failure and pulmonary oedema, and it is my job to take blood from him everyday. Unfortunately, he pulls up a 'tak-nak tak-nak' show every single morning. Come on... I haven't got time for this: I have 27 other bloods to do! What I normally do is to leave him alone for a while and come back after I have finished everyone, by then he would normally be in a better mood for me to poke around. I had a really important job today, which was to sort out his social welfare. His son and his life has been in a mess for years but no one had bothered to properly get the necessary help for him. The registrar had assigned this important job for me. I helped him write support letter, get the social worker to see him, get help for dialysis etc. I was proud that I was able to put aside my vengeance on how he has made my life difficult every morning and rise above to understand that he's only acting like that because he is ill. I am really determined to do this part of my job well.

Thursday

I really hate relatives surrounding the patient when I am trying to take blood or put in cannula. It's ok if it is easy and requires only one shot. But if I have to try 5/10 times before I get it, I feel the pressure as the relatives get distressed for seeing the patient getting distress. Normal people are just not emotionally numb to patient in pain like doctors are. I am considering if I should ask the relatives to go away while I do these next time.

Dr Andrea made everyone wear pink today. We took a group picture. That was really sweet.

Dr Yusniza, my registrar gave me two of her white coats today. Aghr.... now I have no excuse for not wearing it anymore. 

Untraumatic radiology scans requests today. HAHAHA!!!

Friday

Started the day with one of my patients collapsed. Thank goodness she was found before I arrived in hospital, or else I'd be clueless on what to do. Abi, who was oncall, dealt with it impressively. I did my first successful femoral stab for her (with all the surrounding nurses cheering). Unfortunately, we arrested not long after, and we did CPR for 50 minutes - unfortunately she did not survive. Quite sad.

There's another reason for me to be proud of myself today. One of the patient needs cannula for blood transfusion. She's been ill for so long already, she's literally skin and bone. She needs a pink one, but all her veins were of the blue size. The medical students and I had tried so many times - left hand, right hand, left leg, right leg - nothing went in. I was already on the verge of giving up when I thought I felt a small vein on the leg. Went for it, and hurray - it's in. I'm so proud that I persisted and did not go asking for help without trying my best. (at the expense of the patient suffering of course).  

Saturday

Dr Andrea gave me a day off. Will grab the opportunity to study.

Sunday 

It started ok. 4 discharges. Before my ward round finished, my already getting calls. It was only a tidy bit better than my on-call last time. I still haven't finishes the discharge by 8pm. Luckily there was a very very kind medical student to help me with 2 discharges, or else I'll be stuck with discharge and delay the rest of my on-call work by another 2 hours. 

I have still not learnt the art of prioritizing yet. There's new patients from emergency and admitted electively to be clerked in - supposed to be seen as soon as they arrive in ward (take history, examine, take blood, and prescribe medication so the nurses can give them out asap as a minimum) . Also in patient who suddenly has problem like shortness of breath, chest pain - some of which, obviously I need to drop everything and go as soon as they call as it could be a matter of life and death. Finally, there's petty jobs like take blood, insert cannula - not unimportant either because the patients who usually need blood have dengue or electrolyte imbalance who need regular monitoring, and patients who need cannula would have needed it for IV antibiotic or blood transfusion. Many a times when I'm trying to sit down and do something, I get called to do something else, which fragments my job. So 10 jobs becomes 30 jobs because I have to go back and forth 3 times to complete the unfinished work. Of all the jobs amassed during my oncall, only about 50% have been done. I feel so bad because the patient don't get the treatment they need. I've also really not been having time to document everything I've done - this could well come back and bite me in the future (really, of so many jobs I have during oncall, documenting is the least of my priority. But I need to make it the priority to cover my ass). So far, my MOs (more senior doctors) had been very supportive, but I feel the support has gone to the point of burden. Like last time oncall, I skipped lunch, dinner, breakfast and lunch next day just because all these were not my priority compared to clerking new patients and attending to acutely ill patients. Was absolutely totally exhausted. Didn't finish oncall work until 9am next day.

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A House Officer in a Teaching Hospital: Week 1

Day 1

Reported to the hospital at 9:30am. A big pile of forms to fill in. Met another new house officer (HO), Sara. We were supposed to go to another four places to settle the admin stuff: the department of medcine, general admin, security and white coat. Didn't manage to do the latter three because our head of department wasn't around on that day, whose signature is required to complete the latter three things. Allocated to the department of medicine.

Met Abi, the house officer leader. She was so happy to see us because medicine has been very short of HO that she was working oncall every 2 days. I was allocated to work for ward Med5 with Abi, while Sara will be working next door with another HO, Izni. 

I tagged Abi until 10pm that day. Oncall is crazy. Say I am oncall for monday, I will come to work as usual on 7am monday, start oncall at 5pm until 7am the next day, then resume ward work from 7am until 5pm - 36 hours non stop. Jobs include clerking new admission which could be up to 28 overnight, covering the 6 medical wards, cardiac care unit, cardiac rehab unit, high dependency unit and a semiprivate ward all on our own. 

Day 2

Already given half a ward to be in-charged of. Aren't we supposed to be just shadowing on the first week? So scary to be on my own. The routine is we take blood, ward round, request scan, make referral and prepare discharge summaries. Luckily the medical students were around to help out with the jobs - such angels. I was particularly anxious of having to request for scan and make referrals over the phone because my medicine has really gone a little rusty and I don't know the patients well thus didn't always know why the scan was requested. 

Didn't tag oncall but still stayed until 10pm to prepare the next day's discharge so I would have less work tomorrow. Unfortunately it would benefit someone else tomorrow.

Day 3

There was a crisis today. One of the medical HO did not turn up for work and wouldn't answer his phone. Abi said he's been depressed for a while because of the job. So I had to go upstairs to ward Med1 to cover for him. What an experience being the only HO in the ward. With no medical students and another HO to help out, I spent the entire day taking blood. I felt so useless taking such a long time, like a headless chicken going back and forth the trolley. And to make it worse, Abi still wanted me to go downstairs and manage half of the ward. I did go down for a while but was sent back upstairs by the specialist again. 

I have fallen in love the team upstairs here. The specialist is called Dr Andrea. She's amazing. She said there's no hierarchy in this ward, that I can ask anyone anything. Finishing blood so late, by the time I started the discharges it was already 4-5pm already. She and the MO sat down to help me do the discharges - I was so moved! (The first three days were a bit of a shock and I was constantly feeling emotional, I really could have shed the happy tears). It turned out that I needed to call her mobile at 9pm about some discharges and she was happy to help me out. 

My first acutely ill ward patient today. This lady who was suppose to be discharged suddenly complained of shortness of breath. I forgot to think ABC, but I briefly asked the patient some question and examined her, then asked the nurse to do a set of obs and called the MO straightaway. In the mean time she didn't look too unwell so I carried on doing discharges while waiting for the MO. A repeated set of obs was done in 20 minutes - the heart rate had shot up to 133! Just as I began having palpitation and cold sweat, the MO arrived. She asked me what's wrong, and I said I wasn't sure. Then she asked me for differential diagnosis for shortness of breath. That's easy - pulmonary oedema, MI, PE, pneumonia, pneumothorax, asthma etc etc. She said if I knew why didn't I work out the problem myself? Why indeed? Busy panicking perhaps? Then she reminded me that I'm a doctor not a clerk, and taught be how to deal with problems like this in the future. Opps, nearly forgot about that. A good lesson. 

Didn't have time to go to admin.

Day 4

Back to the downstairs ward with Abi. Today I had a strict MO - no mistake allowed. I very quickly get taught how to run the ward round and I learnt quite quickly. There were quite a few jobs to do but I was getting much more organized and was actually finished before 8pm. I then helped out Abi who was oncall again with blood. I spent an hour in high dependency with two very poorly and veinless patients.

Abi broke a bad news to me: said I won't be working in Med5 with her anymore. It was because Sara, the new HO, who was sent to cover the ward Med1 upstairs today could not cope alone, and Dr Andrea was more comfortable with me (I'm so flattered). Abi was quite upset that I was going. I was too. :(

Still didn't have time to go to admin.

Day 5

Yes! Back in Med1. Came at 6:30am today as I don't want to spend the entire day taking blood for the whole ward like the other day. It all went well as planned until about 9am the high dependency kept calling me over to do bloods, cannula, consenting their patients, interrupting my organization. 

The evil plan was that there were 9 discharges today! Luckily the team of my seniors was kind enough to help me with 6, or else I would be staying in hospital overnight. Well, nearly... I finished everything and went home at 11pm.

Still didn't have time to go to admin.

Day 6

Sadly, Malaysian doctors of all levels, from house officers to specialists have to work on weekend. Maybe I did push myself too far yesterday. Felt completely drained, was so slow to do the blood and kept missing when I normally wouldn't. I informed Dr Andrea and Aida about the 2 impossible patient who needed cannula. Today I saw how brutal and heartless doctors with many years of hard training are. In each patient, we poked about 20 unsuccessful cannulae before giving up, ignorant to the patient's moaning, involuntary jerks etc. I am not that cruel yet - I would try up to only 5-6 times before stopping. Again, I'm so moved that they are willing to help me do these house officer's jobs. They inserted proper central lines in them eventually. Managed to escape just before dusk today. Yeah!!!

Day 7

My best day yet. Came in at 6:45, managed to finish blood round by 8:30, even had time to read about the new patients and update the blood results. Joined the round properly for the first time in Med1. It was fun actually. They taught me how to write and I picked up very quickly. Not very dissimilar to the UK, I've been writing round notes since third year. Dr Aida, my MO was such an efficient partner - while I write, she went around doing all the jobs, so they'd be no jobs left for after the round (apart from bloods, cannula, discharge, in other words my job). Dr Andrea complained that I wasn't wearing white coat today. I have to wash and I only have one... And then she said she would give me hers. No no no please forget it. And then she said she would give me hers. No no no please forget it. It's so filthy, people coughing TB, Strep and all sorts at me everyday. Now I am having some cough now. Hope I don't have to take MC. Another fun thing was that my cannulae all went in the first time round! Satisfying. 

Dr Andrea told me that from tomorrow I would have a group of medical students to help me out. In fact, they were already here today to clerk in their patients. Asian medical students are so hardworking - they come in at 7am, weekends and does overnight oncall. I love medical students. 

Went home at 5:30. Bliss.

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This week I am so grateful for my colleagues for giving me the support I need - my specialist, registrar, MO and fellow house officer for giving second opinions on cannulae, helping and training me up for the job, attending to my calls about sick patients, answering my query at 10 o'clock or simply asking if I am coping alright - meant so much. Says who that junior doctors in Malaysia do not get support?

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When she is angry

She is the coolest and the hottest lady in town. An outright extrovert, she expresses whatever she is feeling. Mainly through body language. Because of this, I think she is cool. Sometimes, I sing to her and ask her how was my singing, she would say 'Good, very good...' with a smile while carrying on with her kitchen work and I carry on singing. I really enjoy helping her with her housework because she gives me with a big 'THANK YOU' with the sweetest tone. I thought I was her favourite, but she claims that she has no favourite, and I believe her, because sometimes she always gangs up with the other sisters or even papa against me. But it's ok, I still love her to bits.

She is like the sun. This is very important because when she is happy, everyone else around her miraculously are drawn into the jovial mood. Ever so popular like a hot star, everyone wants to be around her. Even I, the ultimate family loudspeaker cum joker have to bow to this special talent of hers. I'll tell you the biggest secret. I am happiest when I catch her singing, as if I have found gold. Even though her vocal power is nowhere nearly as good as mine, I know that she must be in her own heaven, and I am happiest when she is happy. 

But when she is unhappy (it is very easy to tell, she makes no effort to hide it) mysteriously everyone around her become quiet and uptight, as if a preparing for a stormy night. There are two faces of unhappiness in her. One is of shouting, another is of the silent treatment. Off her wide range of vocabulary, she picks the most cynical words. Fresh off the boiling volcano, her sentences are high in volume, low in tone, furiously dark on her face and completely mad in emotion. The impact seeps into every cells of everyone within 20 feet. It is hurtful, like freshly sharpened knife stabbed straight into the chest for 1000 times. I would not wish of them any upon my worst enemy. 

When this phase dies off, comes the long, silent aftermath. This is a dangerous time because she looks as cool as the black charcoal sitting quietly amongst the woods, but a small wind would set off another raging bonfire. It is at this time that we realize how important she is in making decisions at home. It is during times like this the rest of us at home instinctively want to help around the house, hoping that it will dim her inner fire. However, it is also when we realize we don't know too many of the menial routine at home. We dare not ask her because we fear it would start another fire. and the task remains unfinished and left for her to do, which will make her angry anyway. So, unfortunately, this coping mechanism had long been abandoned. Instead, during this silent phase, we try to stay out of her way as much as possible, until she finally cools down and start talking to us. 

The other night, when she was at the peak of her unhappiness, I was so upset. I wonder if I am selfish, if I only want her to be happy in order for me to be happy. Maybe. However, it truly pains me to see her unhappy. I toyed with the idea of suggesting that we visit the temple (but at the end I chickened). I could only pray in my heart. I pray that she rids herself of this suffering, all those negativity driving her towards unpleasantness. I pray that never again would she set foot into this realm of unhappiness. I love her happy side too much that I would never do anything to make her unveil her unhappy side. But everyone becomes unhappy once in a while and when she is, I pray that she finds a better way of channeling it out of herself, whether it is taking a breath, or just telling me that her temperature is rising is would like to be left alone for the day, a way that does not raise her blood pressure. 

She is my mummy, and our sunshine. We will always love her to bits.

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I love home

Teaching basic life support to Wan Teng.

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Half asleep

The worst nights are the ones when you are sleeping but actually half awake. The worst days are the ones when you are awake but actually half asleep. I had such a day yesterday. I knew the first thing in the morning that it was a bad day. I just couldn't concentrate on anything. I went to Bristol for a surgical conference. I nearly miss my morning train to Bristol. And then at Bristol, I told the bus driver to give me a shout when we arrive at 'The Triangle' but he didn't and I only alighted a few stops after. On the return journey, I got lost walking from the university building to the train station, and therefore missed my train and had to fork out an extra 18 pound.

Before yesterday, I was really looking forward to enjoying the conference. I usually do, I love seeing and get fascinated by all the research and innovation presented. But I don't know what poison got me yesterday. I was just in the totally wrong frame of mind. Maybe because I was presenting, and I knew I was amongst the people competing for the prize. I was saddened that so many posters and presentations had fresher ideas and were more eye-catching than mine. Suddenly I felt my poster was so uninteresting, unappelling and there is no chance I would win. I was also disappointed that some of my friends were selected for oral presentation for really low level stuff like case report whilst mine, a higher level research and involved much more work was only asked to present a poster. I was unhappy because case report is so easy as they only had to pick a clinical case and do some textbook reading (and obviously they have only bothered to present to enhance their CV), whereas study like mine involved thrawling over 100 casenotes, statistical analysis, collaboration between researchers etc etc, i.e. at least 10x harder than a case report, especially when compared those undergraduate level ones they have presented. The negativity overcame me so much that I was neither meeting new people nor looking at other presentations which I usually do. I was just stood by my poster with my arms folded for a few hours in the morning. Is this a classic case of 'kiasu-ness'? I was very aware of this and I kept on telling myself that it was no use feeling like that because a) I was just going to give people a very negative impression of myself b) I was not going to enjoy anything. Later on in the day it became a little better - I was interacting and even had a smile on my face. But I was still desperate to get over this and arrive at Aunty Sheena's place to commence a relaxing weekend asap.



Had I woke up fully awake, I would have been so POSITIVE even if exactly the same things happened:


- I nearly the train to Bristol, but I didn't. Isn't that lucky?

- The bus driver didn't shout me to get off at the stop I wanted to, but the walk to the building from the next stop I alighted from were actually shorter compared to had I got off at the previous stop that I first intended. Saved me 5 extra minutes of walking.


- The nice ticketman at the train station suggested that I buy the ticket to Bristol-London, and then get another one from London-Watford Junction when I arrive at London (rather than Bristol-Watford Junction) because it would work out to be cheaper. I should thank him because on the train, I realized that I didn't even need to buy the second part at all because this part of the ticket for the train the I had missed was still valid as it was not time restricted. Saved 10 pounds.


- My abstract was accepted. And I had a chance to showcase my work. That in itself is an achievement already.


- Questions from other participants in the conference have given me more ideas for me to write up in my publication for this research.


- Is poster presentation inferior to oral presentation? Debatable, but I don't think so. Some who won the best presentation prize were posters.


- I had really enjoyed designing the poster. I have put in a lot of effort into this and I am very proud of it.

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Appalled

There you go Wan Teng - another new vocabulary for you.

I did an audit, and emailed both the statistical analysis and conclusion to the consultant. It consisted two word files and one spreadsheet weeks ago. Our exchanges thus far have been via email. I met him yesterday for the first time since this audit started. 

Admittedly the writings are long winded and painful to read. The second file is easier to read. Page 1 consisted a nice table summarising everything the audit aims to find. Pages 2-3 are the further calculations and conclusions drawn from the table. When we went through the files yesterday, it felt strange that he only referred to the first page, and was analyzing the nice table aloud - of things that I have already analyzed on the next page. So I told him to SCROLL DOWN. And viola, here are all the answers! It was clear that he had just read the first page, not the rest, which I had burnt several thousands of neurones to generate. He didn't read the first file either, which was actually mostly rubbish but one paragraph in the middle. Anyway, I was in a good mood yesterday and I felt he was willing to be more supportive (than before), so all is forgotten and forgiven. 

Hope I will get to do a presentation and a publication on this audit. Wish me luck.

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Using my hands

Historically speaking, I was not the master of hands on skills. I get bored easily. If I didn't do things well at the beginning, I'd quickly get impatient and abandon the task. I used to learn the piano. I love playing but I rarely play anything to perfection. I can count the number of songs I can play without a mistake with my ten fingers. Even up to exam time, I played the wrong note and stop in the middle of the piece. When I played the school song during the assembly in primary school, I always get something wrong every week, and it only started to become note-accurate on the last few weeks of my primary school life. This was how unreliable I was. I feel sorry for people whom I accompanied in singing competitions and choir because the piano part was always bad (but they always ended up winning somehow, and I get some of the credit!). I can sightread and learn quickly but I never had the urge to practise and perfect it. I blame the teacher that I didn't get on with and the broken piano that I had to practise on until grade 7. My carpentry, soldering and needlework in school were consistently horrible. I just couldn't nail two pieces of wood in the right angle, or solder the electronics right so that all the LEDs would light up.  

 

Having to be able to master hands on skills was one of my worries when I was contemplating on studying medicine. Having seen numerous GP having multiple stabs on me and my family when taking blood before I went into medical school, I had the impression that it was a very difficult thing to do and I didn't think I was ever going do it well. If I have to turn out to become one of these doctors so unskillful that I have to stab my patient multiple times, poke around underneath the skin for several minutes before I could get the blood out, I'd rather not do medicine at all. I had the same thought about the many other skills required of a doctor. I was seriously doubtful of my own ability, unsurprisingly given my history. But, as you all know, I have stuck with medicine in the end, and I knew I just had to put in the effort to learn them well no matter what it would take.

 

They turn out not to be not as difficult as I imagined. There are steps to follow for every procedures in medicine. For example, in venupuncture (taking blood from a vein), I have to prepare all the equipment, consent, put on the tourniquet, find a vein, clean the skin, warn the patient, stick the needle in, withdraw the plunger, disconnect the bottle, release the tourniquet, withdraw the needle, press on the site and then apply the plaster. I know, too many steps it seems but I have done it do many times that it now feels like a fluid one step action. In an exam, we must demonstrate as if we have done all of these for a hundred times (we call this 'slick'). For nearly every skill the medical student would have to learn, we get a few practice on the dummy first. Dummy resembles very little of the real human, but it allows the novice to get the order of the procedure right. Then when moving on to the real patient, we learn how to shake off our tremor, take time to tap out a juicy vein and dealing with the anxious needle-phobics, in other words steps not included in the textbook but practically essential. In my third year, I would only practise on someone very easy to bleed and gradually I started to do it on more difficult patients. I still miss sometimes (and senior doctors have reassured me that everyone miss at some point), but I am getting there. I don't think I am not as bad as I imagined myself to be. 

 

I have ended medical school rather liking to use my hands. From the very start, because I was really motivated to be good at these skills, I was constantly on the look out for anyone that needs blood taken, cannulated or catheterized, and would leap to the chance to do it. As a result, I am relatively ahead of other people in my year. Compared to the average student, I have done the basic procedures for more times, have tried it on more difficult patients and have moved on to learn more advanced skills. Consequently, I also get a fair amount of positive comments and encouragement from doctors supervising me. All these have made me rethink about learning to use my hands. 

 

Of course, I am writing these because I am seriously thinking about becoming a neurosurgeon. I have never thought about doing surgery before because I didn't realize the skills element to it. I know it's a bit thick of me to say this, but in my third year, when I go into the operating theatre, all I would do is to stand of the corner and watch the operation from afar, occasionally being questioned on my anatomical knowledge. It was boring. In the fourth year, I started playing the retractor but it wasn't the hardest job in the world and certainly didn't require a lot of thinking and learning, so I was bored although it was much better than just watching. Fifth year was quite different. When I was attached to the urology firm, I wasn't expecting many opportunity to scrub up because most of the procedures didn't require an assistant. My consultant and registrar knew I had turned up regularly in theatre and had observed many cystoscopies and circumcision. So on my last week, I was asked to do part of these operations myself. I didn't expect it because we do not normally learn to do operation as undergraduate, usually only the surgical trainees get this sort of operating experience. Eventhough I wouldn't say I have done a good job, I was really thrilled because I was experiencing something new. It was like I have suddenly come to a realization that surgery is just like learning how to take blood. In the end, urology did not appeal to me, but surgery did. On my first day in neurosurgery, the consultant was positioning the patient's head but I wasn't concentrating thinking that I probably wouldn’t need to know this anyway. He said to me 'You have to look carefully Yee Yen, because the next time, you will be doing this'. Yes, such a big difference it made being told that I will actually doing it next time! That was my mistake. It was the equivalent of the difference between hearing and listening. This is the reason why I was bored of theatre before this, because it was just like watching a film, not needing to learn anything out of it, so passive. It was as though I was in theatre just to sniff the air, have a feel of the atmosphere. Since then, I always concentrated when observing an operation as if I will do it next time. I knew I had to assist from time to time, so I observed carefully how to do it well. And every time I did something, even simple things like scrubbing up or suturing, I thought to myself: this time has to be much better than the last time. I could see my skills improving with time, and it was extremely satisfying. As of now, none of my skills are perfect yet and it makes me want to practise them more often so I can be perfect. One day, I was doing quite a lot of procedures, and the anaesthetist said 'you have done many things today, haven't you? Cannulation, catheterization, intubation,' 'removal of meningioma..' the neurosurgeon continued. He was joking of course. I didn't remove a brain tumour that day, but one day perhaps? To put brain surgery side-by-side with skills which I already am doing it seems not too distant a dream to pursue. 

 

Ever since my surgical placements, I have become increasingly frustrated to not be allowed to do things that I knew I can do (either because I have done it before or I have seen it for so many times). The problem with undergraduate medical education is that we don't get enough hands on experience. Occasionally, consultants speak of some ‘back in those days’ stories, about things they did as medical students like administering anaesthetics alone, washing out wounds, having to deliver 20 babies etc. I was meant to sympathize them because it was hard work but instead I am rather envious of their experience. I wouldn’t have minded the hard work at all. These days, we just do not get taught anything other than what are immediately useful for us, and these surgical skills would not be. I was lucky that I had such keen and passionate teachers. Without them, I wouldn’t have realized what being a surgeon is really about.

 

Back to music, since coming to Manchester and joining the chorus, I saw with my eyes and heard with my ears some of the most talented musicians and the most rhythmic pianist play, how grand a sound an orchestra can make. I feel inspired to be like them. I know how they do it: practise, practise and practise. Anyone can do that. I am now practicing three pieces to accompany my younger sister for her violin exam. (She has also recently been enlightened about the point of practicing, read her thoughts here). I have been practicing everyday for nearly two weeks now and I am not yet bored. I really enjoy practising. I like really concentrating getting a part right, do it again and again and again until it's perfect. Even for scales, when I can do it perfectly in the tempo and ‘legato-ness’ I want, it’s immensely satisfying! But what do playing the piano and neurosurgery have in common? The fine motor skills. When assisting in a spinal surgery once, I was asked to hold a retractor gently under the microscope. I was nervous because my consultant said ‘don’t pull too hard, the ability for the patient to dorsiflex (cork his foot) is in your hand’. I had to concentrate quite hard to do it. There is definitely no room for clumsiness or complacency in neurosurgery. I am still not entirely convinced that I can do it. I need to prove to myself that I am capable of learning to use my hands to operate on delicate structures of the brain and spine. I think it would be harder than venupuncture, but less difficult than playing the piano. So, with regards to skills, I have set myself a challenge. If I can persevere to get a merit in grade 8 piano, I would go ahead to train as a neurosurgeon.

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Last concert

Last weekend, I performed in my last concert with the university chorus. It felt very under-rehearsed on Thursday but we have come a long way over the next two days. Saturday's concert was so-so (It sounded like a good rehearsal but not up to performance standard) but Sunday was great. One particular phrase of the Te Deum (Verdi) always gave me headache as I strained myself to sing it all in one breath (if you can read music, it's the highlighted bit).

 

I said good bye to several people whom I don't think I will meet again. It's quite sad, but at least I take away good things and nice memories. I have enjoyed the chorus very much and have learnt so much from two very capable conductors. I hope I can share this with some music lovers when I go back home.

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Should I be a neurosurgeon?

The neurosurgery placement for the last four weeks was a perfect career taster, and I found it very palatable indeed.

Before my fifth year, I had swear I would never ever do surgery, mainly because I don't understand how I could enjoy it. But my perception has changed in my fifth year as I am allowed to do more in theatre, sometimes even performing part of the operation itself. Neurosurgery had been especially exciting. I have never enjoyed theatre sessions so much before. It's amazing to be able to see the dura, then the wet, shiny arachnoid mater so beautifully covering the brain. I love the rough part of the surgeries when they split the thick scalp and drill holes; and also the delicate part of dividing the arachnoid and dissecting out structures of the brain to make everything clear. The view under the microscope is exceptional. In spinal surgery I could see very clearly all the different layers of muscles in the back before the disc or spinal cord is reached. Utterly spectacular! I really want to learn all to do all those things even if it takes ages to train.

I was given lots of hands on opportunities in theatre. My registrar wasn't around on my last day, so my consultant said to me: 'You are not a medical student today, you are a surgeon' as I was his only assistant. I have assisted in craniotomy before, but never alone. I thought I would hinder more than help, but at the end I think I did well, knowing what to do at the right time with relatively little prompting. We discussed the operation like proper surgeons and he even accepted my suggestion of putting an extra clip for the aneurysm he was clipping. The operation went well, and there was a sense of pride when my consultant wrote my name under the 'surgeon' heading in the operation notes. My consultant was the nicest teacher who never stops encouraging, which was what I needed most as I was losing focus and initiative post-exam. I regained my enthusiasm and managed to get lots of procedures done during this placement - including my first ever cannula on the foot, removing drain from the brain, intubation, suturing the scalp and lots of catheters. I spent a week at the neuro HDU - a place where many of the neurosurgical patients end up, helping the team to review patients. I diagnosed a case of SIADH and another one of diabetes insipidus there - two conditions that we are expected to know quite well but rarely seen in real life. These complications of neurosurgery conditions (surgery with medical/endocrine interwoven) make me very excited indeed. I also did many days on-call, which was tiring (I was at hospital from 8am to 10pm on some days) but very fulfilling experience as they were literally rehearsals of my first job as a doctor. I enjoyed being helpful to other people. I was rewarded by a ride back home, a free lunch and being taught how to tie knots by two junior doctors for being helpful. I enjoy the variety of work as a neurosurgeon.   

I think I would find this job very rewarding because neurosurgery can change people's life for the better, whether it's evacuation of subdural haematoma or removal of meningioma. I fell in love neurology and the brain ever since the first time we met in our second year in medical school. It wasn't easy, I remember spending ages memorising the foramen on the base of the skull and what pass through them, but I loved it that at the end, when you understand the map and the routes (like formalae in math), you'd be able to solve clinical problems logically without the need of sophisticated tests or scans. 

I still can't believe it but I am seriously thinking about being a neurosurgeon.

Good points:

I love the neurosciences. I can spend all my life with neuro and still wouldn't get bored. I'd like to think that I am intelligent enough to pass all the exams, and if I'm not, I'm prepared to work hard for it. I am not at all put off by the long hours and heavy emergency work load because I like the rush.  

Bad points:

Neurosurgery can make a big difference to people's life, but things can go wrong - more often than other specialties, and when it does, it ruins people's life. Neurosurgeons make difficult life and death decisions everyday. The decision making process (most commonly - to operate or not) is interesting but you have to take risk ultimately and I know I don't like to. 

I don't mind not having a life at the moment but the time will come when my life becomes messy. Neurosurgery isn't necessary conducive to family life, they come in early and leave late almost on a daily basis. My registrar was on-call so often and always stays on in hospital until 10 pm on his normal days I wonder how he manages to maintain the relationship with his wife and children.   

Now that I have withdrawn from the UK foundation programme, I don't know how easy would it be for me to get on a training rotation for neurosurgery in the UK or indeed anywhere in the world. Other countries renown for training in neurosurgery tend to favour applicants from developed countries, at least that's the impression I get. In addition, I am also at a disadvantaged position from the competition point of view as I do not have any intercalated degree, publication or prize. I know I shouldn't give up just yet, but the FY1 whom I worked with at NHDU may be right - final year in medical school is probably too late to only start considering a career in neurosurgery.  

I'm feeling a little miserable now as I can't imagine how achieving this ambition is going to be possible. Any comment/advice? 

P/S Just want to draw your attention to this article that I read. I can relate to this guy very much. I too do not have a work life balance, much as I try to. And I too, wish that I wouldn't have to retire and would be able to carry on doctoring until I expire. I have seen him on TV and I like him. I hope to be like him or my consultant one day. 

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My personality

Your view on yourself:
Other people find you very interesting, but you are really hiding your true self. Your friends love you because you are a good listener. They'll probably still love you if you learn to be yourself with them.

The type of girlfriend/boyfriend you are looking for:
You like serious, smart and determined people. You don't judge a book by its cover, so good-looking people aren't necessarily your style. This makes you an attractive person in many people's eyes.

Your readiness to commit to a relationship:
You prefer to get to know a person very well before deciding whether you will commit to the relationship.

The seriousness of your love:
Your have very sensible tactics when approaching the opposite sex. In many ways people find your straightforwardness attractive, so you will find yourself with plenty of dates.

Your views on education
You may not like to study but you have many practical ideas. You listen to your own instincts and tend to follow your heart, so you will probably end up with an unusual job.

The right job for you:
You're a practical person and will choose a secure job with a steady income. Knowing what you like to do is important. Find a regular job doing just that and you'll be set for life.

How do you view success:
You are afraid of failure and scared to have a go at the career you would like to have in case you don't succeed. Don't give up when you haven't yet even started! Be courageous.

What are you most afraid of:
You are concerned about your image and the way others see you. This means that you try very hard to be accepted by other people. It's time for you to believe in who you are, not what you wear.

Who is your true self:

You like privacy very much because you enjoy spending time with your own thoughts. You like to disappear when you cannot find solutions to your own problems, but you would feel better if you learned to share your thoughts with a person you trust.

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Poor surgeons

News are running wild in my hospital regarding a surgeon, when performing an operation for ectopic pregnancy, ruptured the aorta accidentally, resulting in a rather disastrous bleed. I have heard various groups of people talking about this over coffee/lunch. With medical students and the surgeons, we generally want to know what happened, how's the patient and how's the surgeon as when things like this occur, it is as traumatic an experience for the surgeon as it is for the patient. Today, in the middle of our little chat, a theatre manager came in and her gossip agenda couldn't be more different. She wanted to know who the surgeon was, whether he or she's usually good or not and who is to blamed - very inflammatory. There was no concern for the wellbeing of the surgeon at all. This just goes to show how little sympathy lay people have for the medical profession and it is up to us to support each other. In this day and age when suing doctor is the norm, we are especially cautious and spend far too much time documenting things, filling in various forms so we are able to defend ourselves. I know it is people's right to complain or sue when they are unsatisfied, but no doctor is ever intentionally negligent. 

Surgeons work extremely hard. Most of them go out of their way to acquire skills. Take my registrar for example: he turned up in theatre this morning after only an hour rest as he has been on-call all night last night just so he could operate in theatre today. He is not alone. I know of many trainees who come in during their free time or stay behind late just for the opportunity to practise and operate. If you want to be good, you have to make this sort of sacrifice especially in surgery.    

Doctors are conscientious. It is generally against our intuition to do things that we are not confident of. When I am asked to do a difficult cannula, I am usually reluctant.  The easy thing to do would be to hand it over to the senior doctor and say 'You do it, it's too difficult and I don't want to stab the patient too many times'. But in fact that is the wrong thing to do. The right thing to do would be to just go for it, and if I fail to try again, and again until I get it. But by then the patient would have had three needle pricks already. However, thanks to this patient, I am more competent of doing cannula. The same with surgery. Reluctant and unsure as the trainee may be, there is no point just watching the same things over and over again. The best way to learn is to get your hands dirty and actually start doing it. But is this fair to the patient? Maybe not at the moment. But if you want you or your children and grandchildren to be treated by the best doctors and surgeons, then the answer is absolutely yes.

Doctors make mistake. In my fourth year, I watched my consultant calmly deal with a bleed from the uterine artery that the registrar accidentally cut. Of course, he had made all the mistakes while he was training already and was therefore confident to deal with anything. In surgery, surgeons generally prefer everything to be well controlled (or boring in the eyes of the medical student). But, a trainee surgeon generally has to do lots and lots of the same operation to achieve this relatively god-like state, which means that the first couple of patients will inevitably suffer as the surgeon hones his surgical skills. The more junior we are, the more supervision we get. The patient is usually not informed if the a trainee is operating instead of the consultant (but it's always documented in the operating notes). Is this ethical? You tell me. I think it is. No surgeon should become consultant until they have encountered and dealt with mistakes. If we tell the patient it would provoke too much unnecessary anxiety and training opportunities for surgeons will decline even further.   

Back to my point of lay people not being very sympathetic to the surgeons. I am really sad to see an eminent surgeon go down this road. I have been to her clinic once. She is an excellent surgeon and no doubt have saved many lives before. Unfortunately because of this adverse incident she is brought to disrepute. Such a waste of a highly trained surgeon. I don't think she deserves this. I hope this post has shed some light from the surgeon's perspective. I'm not saying that surgeons shouldn't take responsibility for the complications from the operations. Every operation carries risk, (and it is unrealistic for the surgeon to list every single one while consenting), so when you the patients agree to an operation, you should have agreed to accept the risks. Surgeons do every operation very carefully and would never have intended to do any harm. And when things go wrong, they don't deserve to be criticized and condemned as if they are some ignorant and incompetent second rated doctor. Have a heart for the poor surgeons.

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One of the OSCE stations

Instruction outside the station: Please examine the patient’s heart

 

Me: (Introduction, Some difficulty with exposure as the lady was shy to take off her bra. Then Inspection, Palpation and Auscultation, then turned to examiner)

 

Examiner: Are you finished?

 

Me: Yes, I think so.

 

Examiner: Are you sure? No other examination to do?

 

Me: Yes, I am sure.

 

Examiner: Ok. Present your finding.

 

Me: On inspection, the lady looks comfortably at rest with some malar flush on the face. On inspection of the precordium, there is a median sternotomy scar. On palpation, there is no parasternal heave or thrills. On auscultation, I can hear an ejection systolic mummur loudest in the aortic area radiating to the carotids, There is no basal crepitation or peripheral oedema.

 

Examiner: Anything else?

 

Me: I think I heard a prosthetic valve click as well.

 

Examiner: Which valve?

 

Me: I’m not sure.

 

Examiner: What do you mean you are not sure? Did you listen with your stethoscope?

 

Me: Yes…

 

Examiner: Well? Do you know how to listen with your stethoscope?

 

Me: (A little taken back by his rudeness!) Yes, I do know. I think the click was loudest in the mitral area. 

 

Examiner: Only the mitral area?

 

Me: Well, I think so. But I think there is definitely two separate clicks on each of the first and second heart sounds, especially at the aortic area.

 

Examiner: So you heard clicks on the mitral and aortic area?

 

Me: Yes.

 

Are you saying that this patient has a combined aortic and mitral prosthetic valves?

 

Me: Yes.

 

Examiner: Good. Thank you. You may leave.

 

 

After being mocked on my auscultating skills, I was sure that I have failed this station. Turned out to have been award 6/7 for this station! The examiner had just put the diagnosis into my mouth. Luckiest escape ever. Just had to keep saying yes. :)

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Comm skills deception

I'm annoyed today. We (the fifth years not on elective in my hospital) were sent an email a while back telling us that we have to attend a mandatory communication course on health promotion. We were warned that if not we will be sent to the hospital dean to explain ourselves.

So I left the morning clinic at Wigan early to take a train to Manchester then another bus to Hope Hospital where it was held. I had to rushed all the way and reached just on time. Then I heard people around saying that it was apparently not mandatory.

After that the people running the course came in to start. What a surprise to be told that we were actually the guinea pigs for this course that they are only piloting and we were expected to fill in stupid long questionnaires before and after the session for evaluation and research purpose - our response would tell him if they should THEN make it mandatory to students in the year below us. They also had the cheek to ask for volunteers on the spot to be tape recorded for some psychology dissertation. Normally medical students are quite willing to help out with experiments, but they have gone too far this time. Only 4 out of the 25 or so there volunteered (later 2 others came forward - ?out of sympathy - I don't think they deserve it).  

It's unfair. I was raging because I felt duped into coming. I pulled a 'black face' throughout the three hour session. Luckily my group tutor was obviously not a fan of communication skills teaching business (as much as he tried to hide it). Didn't stop me from complaining. Do they realise how time consuming and expensive it is to travel to the teaching hospital when you are based on a district general? The journey that would normally take 30 minutes by car took 2 hours by public transport, and cost me £6.60 (I spent a ridiculous £13.40 on that day just on public transport!). Do they care?

I didn't find the course useful. I found it painfully patronising. My colleagues, maybe out of politeness albeit with a doubtful tone, said it was useful, but would have preferred a three hour teaching on neurology instead. My tutor remarked that he also would have been more comfortable with teaching us neurology for the last three hours.

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The Finishing Line

The few weeks towards the exams were the worst. I did not do any revision over the Christmas holiday. I did not develop enough sense of urgency to start revising yet. I remember thinking what else it is that I could possibly not know? I kept on telling myself to open the books and start memorising things, but I was much more interested in Doctor Who and the whole lot of tantalizing festive programmes on TV. The intensive revision really only started on the 3rd of January (and my exam starts on the 13th), when the medical school's revision lectures started. It turned out that there were indeed many things that I still do not know, but the rest of my year does, which was scary. I learnt and memorised more things that I've ever had in the 10 days. As with the previous exams, I felt I was never going to have enough time to cover all I wanted and wished that I'd started earlier (and always promised myself that I would start revision earlier next time but I have never fulfilled this promise before). I was also doing practice questions and found out even more things that I apparently should know but didn't. I was consistently getting 60-70% while I expected nothing less than 80% by that stage, so it worried me.

Then there is the pressure. This is THE exam. I pass, I'm a doctor; I fail, I'm not a doctor. During the OSCE, I thought of how unfair it is that all our doctoring skills that we have learn in the 5 years be judged in merely 2.5 hr by strangers who never knew us. There were too many people that I didn't want to let down. My parents - they have been very supportive with plenty of encouragement. They also went to the temple and prayed for me. They and my sisters were really the only people that I could talk to about how stressed I was, but I tried not to because it would make them worry and feel helpless. Then there were the two senior doctors in the Chorus with me. They were each my consultant and tutor previously and I know that when I return to rehearsal in the new term, they would go 'So?' with regards to the finals. Last year, I was told that only 3 out of the 20 Malaysian students passed the exempting exams, making me feel worse.

I don't know why, but people always say to me 'Don't worry Yee Yen you will never fail. If you fail, what hope has other people got?'. If they have realised that I just wasn't as good as I used to be, they will understand why I was so genuinely worried for a very real possibility of failure. I messed up my PMP - It was in a difficult format and I didn't know the answer to half of the questions. Throughout January until the result was released, I was an emotional wreck. I would burst out in tears for no good reason, and go on crying for hours, drowning in self pity. It was worst after the OSCE as I was convinced that I failed. In the morning of the OSCE, two buses wouldn't take me as I didn't have small change (but the third bus driver let me on without charge). I took it as a really bad omen and just spent the whole 20 minutes journey on the bus crying. As a result, I was a few minutes late for reporting. I wasn't myself throughout the OSCE. I did well in two or three stations (managed to keep my hands at the back and looked professional because I knew my stuff) but the rest stations were either average or bad. I managed to make silly mistakes like not requesting a pregnancy test for ?ectopic. I wouldn't disagree if the examiners thought I wasn't fit to pass. Very sad. I was supposed to pick myself up quickly for the last paper in 2 days time, but I couldn't. I did some revision eventually, but I didn't put in full effort as I thought, what's the point, I've already failed. Luckily, the progress test wasn't as bad.

After the exam, we went out to eat and had a good rant. It made me feel better, but still I needed to prepare myself for the results. I have a plan of what I would do for the resit. I would get two revision books, do lots of practice questions more consistently and prepare for past year OSCE questions. I told my parents not to expect good news. While I was in London, I also told my sponsor that its likely that I'd have to resit. I was travelling from London back to Manchester on the day the result was due to be released at 1pm. When I booked the coach, I thought should I arrive at 1 or 2? I settled for 2pm. The later I know, I less pain I'd suffer. But as I arrived in Manchester, I found myself rushing back home to check my results on the internet. (But at the same time still reminding myself to not get too excited as I'd only be disappointed after).

'Year 5 Exempting Examination Results' was the first announcement. I opened the announcement, clicked on the Y5_Exempting_Results_Grid_Jan_10 pdf file, scroll through to find my library card number, and read carefully.

PMP and PT - H

OSCE - S

Outcome -Pass - Exempt

What?! Hah! I closed it and opened it again. It was the same. It was only then, I dared to think about actually being a doctor! I PASSED THE FINALS!

I won't make an Oscar speech here but I'd just like to say how grateful I am to have such a wonderful family. Mummy, we are the product of your sacrifice all these years and you are responsible for the person I am today. This is your success as much as it is mine. I think you have done a great job!

My friend had written a more detailed account of the OSCE exam here. It's very brave of him to reflect so openly. I can't, I'm still suffering from the post traumatic stress...

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The Road to Finals

I am going through an anticlimax. It was not a short battle, so I do not expect this to resolve in a blink. Let’s recollect.

Finals. Every final year medical students start worrying well before the beginning of final year. This is the most important exam in medical school. Everyone know it, the students, the teachers and even some of the patients!

I started thinking about it much earlier. For a while in my third year, I was very confident with my own ability. Although I was just as disorientated as my fellow friends who have just started the clinical year, I worked much harder then many of them. I was often ignored in wards and clinics but I persevered, always with the endless questions and getting excited over new things I learn everyday. The effort paid off. I was better than my friends and even some junior doctors. I thought I would pass finals easily even if I was thrown into the final exam then. But I also felt increasing alienated by my friends for being different. I was always alone because no one shared my enthusiasm.

So although I still see patients more often than my friends, subconsciously, I toned down this obsession in my forth year. The relationship with my friends improved. But the medical side of things suffered. I was average and did not always have the extra bits to contribute in group discussion like I had in my third year. All in all, fourth year was a fantastic year, although by then I was no longer boosting with confidence like I used to.

Fifth year started badly with disappointment over my research project not being accepted for presentation in a meeting that I was really looking forward to attend. I felt crossed because people were full of praise about my work. Have they just been lying to me all these while to make me feel good? For a whole month, I buried myself under the duvet. There was a background worry about finals but I just did not have any motivation to revise. My supervisor’s ex-students had always managed be accepted for presentation in those meetings in the past, I am the only stupid one. I felt as worthy as a piece of dirt on the floor. I hardly told anyone about this because I felt so humiliated. Then, on the next placement with the geriatric firm, I was surrounded by patients again and felt better as I was a valued member of the team.

The GP placement made me rethink my clinical knowledge. I saw many patients on my own but was only confident with the diagnosis and management in less half of them. I would never forget the instance that I made a diagnosis of biliary colic even though in the history I knew that she had lost 20 kg in a short space of time. My GP was critical that I have not referred her urgently to the hospital. How lucky she was that I wasn’t yet a real doctor. I saw her scan later - she had widespread cancer all over her liver. I used to think ‘worst-case scenerio’, but in GP land, as common things are common, I sometimes forgot to think through the wider list of differential diagnosis, instead I tried to make it fit into benign story. It scared me and rocked my confidence level big time. To imagine that I have to be able to figure out what’s been wrong with every patient that comes through the door and be able to initiate treatment is horrifying. I am not ready to be a doctor. I am not going to pass finals and maybe I don't deserve to.

On the other hand, the gap in knowledge in the whole year group narrowed and we all knew the same thing more or less by then. My extra effort in the early years was null as everyone else have caught up. I was definitely not top of the class anymore. I didn’t know what else I could do to raise my game. So, well into my fifth year and I am well blended with the rest of my friends academically and socially, yet I am not a bit confident to be a doctor.

TO BE CONTINUED…


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