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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