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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