Travel

After scraping through my Psychiatry exams, I was able to take a breath of fresh air. My muscles were finally able to relax and I could slouch in a lazy sort of way. Third year is now behind me and I can focus on the challenges of 2012... But not before heading out of the country for my elective term.

I'm not sure how electives work in other medical schools. Our elective rotation is at the beginning of final year. I chose to organise my own like most other colleagues and decided to go to the hospital my parents met, where I was born.

Istanbul has been quite an experience so far. Traveling is certainly different and seeing another country's people (even if I'm one of them) is always an eye-opener. The culture is so different, so vivid.

The history is vast, stretching from early Christianity through multiple Empires and resting in the hands of the Turks. Walking down the cobblestone streets and hearing the sounds of the Imam calling the people to pray is just something else. There is a sense of affection in the atmosphere, where you can approach anybody with any question and they will greet you with a sense of respect I barely experience back at home.

Witnessing courtesy upon public transport was magic. Watching the young make room for the elderly, offering them a seat or a hand was amazing. One lady entered the bus via the backdoor with a large suitcase because it was very crowded. She struggled to get her bus ticket out of her purse and then I saw the people pass her ticket from one to another up to the bus driver and back. Such a commonplace occurrence here, unheard of back in Sydney.

Aside from sight-seeing, I've been able to concentrate on absolutely nothing. Just looking around, breathing in the cold air of the Northern Hemisphere, taking in the scent of the soil and occasionally tuning into some conversation.

People start asking what it is you want to specialise in once they realise you're in the final stages of a medical program and I've said "general surgery" so many times that I'm not sure if it's really what I want to do or what I just keep telling people what I want to do. I didn't get as much out of my surgical rotation as I'd wanted and I'm taking advantage of the elective term to be sure general surgery is the way to go.

I speak to colleagues about their career choices and some of them are so certain in their decisions that it baffles me; I'm not sure if I should be happy or feel sorry for them. I've already seen some colleagues crumble at the very hint of second-guessing their career choice and it saddens me to see these potentially amazing doctors devote to a certain field so blindly. The irony is in the simple fact that it's not their fault.

Somewhere under here is a medical student
experiencing role confusion.

We've all experienced some degree of role confusion in a hospital. A patient or their relatives might've mistaken us for a doctor, for example. Some of us have also felt the pressure of role confusion, when a nurse might've asked us to write up a medication in a patient's chart knowing the doctors were long gone. We eventually become part of a team and commonly the work is so intense, our role as an observer is violently crushed beneath the boulders of responsibility. Naturally, we believe that we have a reasonably good idea of what a team's specialty is about given our participation and our career choice may largely be determined by the level of responsibility given. Also, not mentioning how nice a team was and how that influences a person's decision in career would be criminal.

I find myself in this state of relaxation and it has allowed me to feel my insight into the field of surgery and how limited it may be. As a medical student, it's easy for me to criticise the work of other doctors and healthcare professionals without feeling the pressures of time, a pager and several registrars on my back and the handful of consultants on theirs. Once I think of all this in a non-stressed state, the accumulation of doubt about my career choice doesn't take long.

So the question that many non-medical friends ask remains: Why Surgery? And maybe I should take a shot at answering it:

For starters, it allows me to offer very intimate care. In my mind, accessing the workings of the body with the understanding of anatomy is as close as you can get to any patient. I believe obtaining consent from someone about dissecting their tissue planes is not only professional and ethically crucial, but also an important part of the healing process. Patients often present to surgeons when all other medical efforts have failed, meaning that in most circumstances surgeons offer hope and care in time of greatest need. I want to offer such help to people.

Within me there is anger toward the next generation of doctors. People are enthralled in hobbies, television shows and many other things that hibernate the active mind. An alarming proportion of these have university degrees and professional responsibility that require more than a person's ordinary attention. Hospital administrators and the justice system have put in place laws which literally strip doctors of their licenses due to misconduct, unprofessional behaviour and negligence. No no, the fact they exist doesn't disgust me... the fact they're necessary does. It's obvious these 'practices' have become so common the entire cohort must be forced to recognise them. The essence of all this? The moral code that once would've stopped medical practitioners has now eroded into the sandstone of standards. Therefore, society's examples of morality now lay hesitant not because it's wrong, but because they can be prosecuted.

Also, what is this bullshit about working hours? When one loses a credit card, there's a 24-hour phone line to call so your limit doesn't get maxed out in 5 minutes. When shit hits the fan because the plumbing's blocked, there's a 24-hour plumbing service so you don't have to take a week of annual leave cleaning shit off your business shirts. If you're hungry after a late night, McDonald's is open 24 hours a day, seven days a week. So what? Doctors are only available 9am to 5pm Monday to Friday? Why? Because after all the education, training and research, there are more important things deserving attention like Bondi beach, Gucci and Mercedes Benz? Get serious.

Patients need our help and if we are to be their go-to general practitioners or specialists one day, we must make ourselves available to them when they need us, not when there's a spot in our dairies. Doctors are public servants. Yes yes, our children, spouses, parents, siblings are important too; but we took on a moral oath when we decided to pursue this... or did we?

As a surgeon, one must be available at all hours of the day for long periods of time because they are required in dire need. You can't tell a patient with a knife through his/her abdomen that they'll have to wait until you finish your 18 holes. Same goes for patients dying of cancer. Yes, it can take weeks for a tumour to kill someone, and that may justify taking your time... but if you were living with something growing inside trying to kill you, every minute of that experience would be horrifying. Other specialties are more forgiving and it's the main reason people abandon their surgical aspirations. Of course, one must be realistic - there are waiting lists and patients must be prioritised, tragically sometimes according to their socioeconomic status.

But someone has to do all this. I want to be one of those people. I want to offer people care when they need it, not when I feel like it. And yes, I want to be taken seriously and not appear too stupid in front of my colleagues and patients... hence, being a Physician is out (because I don't think I'm smart enough). Psychiatry is emotionally taxing and whoever thinks it's an easy specialty seriously needs revision; perhaps even ECT.

Here I am, eager to be useful, trying to help and I'm optimistic about this elective term in general surgery. Our Dean of Medicine once told us about some research done on medical students suggesting the elective term as being the most career-changing rotation in our clinical years. It has gravity. There are reasons why I want to do surgery, but also reasons why it may not be such a good idea. I must continue to think it through carefully. Slowly but surely.

A Day in Psychiatry

Psychiatry was a roller coaster ride for me. It went up, down, side-to-side and it was enjoyable for a while. I was on this ride for eight weeks and I'm starting to ask myself "Was this real? Or was it just a ride?" Seeing patients with such disabling, dignity-stripping illness crippled me and I had trouble composing myself on a day to day basis. I looked for ways out - I wanted to leave early, take days off and try what I could to avoid the ward.

But Dr. BB, my supervising Psychiatrist, was adamant that I stay for all activities and help him in any way I could. I really enjoyed working with him and watching him speak to patients. There was something about his mannerism and passivity that was therapeutic even if I wasn't the one sharing my worries and stressors. He emphasised principles that few consultants paid attention to, such as introducing oneself as one the caring doctors and asking "do you have any questions for me?" It was these qualities that enraged me when he asked me to attend the ward on the Friday after the exam was over... but it was also the same qualities that propelled me to come in. 

One afternoon, I was milliseconds away from a total public breakdown. On morning handover, we listened to the supervising night nurse explain the inpatients' behaviours over the last twelve hours or so. The tone was very "us against them" and even more "I've heard all this before. What's for breakfast?" Dr. BB asked me to attend the Electro-Convulsive Therapy (ECT) session that morning. He said he would join us (the students) later and Dr. ZN, one of the unaccredited Psychiatry registrars, was in charge of the session.

J, G & I headed over to the outpatient's clinic, where they had a room with an old bed beside an even older set of anaesthetic monitors leaning on antique exercise equipment that was gathering dust since the hospital declared them unsafe for patients. The very atmosphere made it clear the hospital wanted to forget patients undergoing ECT as much as they did the lawsuits that were a consequence of faulty exercise equipment. 

Dr. ZN was an overseas doctor who passed the admitting exams in Australia. I had already spent a couple of weeks with him in C-L Psychiatry earlier in the term and he seemed nice enough. However, it became quite clear the admitting exams did not test empathy or basic common sense. 

Ashley, the first patient on the list, was wheeled in. The anaesthetic team was there, waiting for him. He was a young man with schizophrenia with such profound negative symptoms that the Psychiatrist believed he would benefit from ECT. Dr. ZN was with us by the corner of the old bed explaining the differences in parameters with the ECT settings, why one might be better than the other and the idea behind it. This all happened so quickly that before we knew it, Ashley's face was but a few centimetres away from our backsides. We didn't even notice before the anaesthetic nurse said "watch your step" as he plugged the ECG leads in. It was then we realised we were literally rubbing shoulders with each other and that we should probably give the poor man space. 

Dr. ZN couldn't care less. He proceeded to explain the voltage, amperes and hertz he was selecting as poor Ashley's head was beside Dr. ZN's waist. I could feel the rage building up inside me. The disgust really started when he pulled out a couple of alcohol wipes and proceeded to hold Ashley's head and wipe it down as if he were cleaning a mud stain from the top of a leather boot. I was surprised Ashley stood still. He didn't explain what he was doing, why he was doing it and Ashley didn't even know his name. 

As Ashley was wheeled out after his medically-induced seizure, Dr. ZN continued to explain his waveform and why it was a 'good shock'. 

Elaine was our second and last patient for the morning. She was wheeled in by one of the mental health nurses as she cried her eyes out, begging all of us not to proceed. Unfortunately it wasn't up to her, as Dr. BB presented her situation to the medical tribunal, who agreed with involuntary ECT for her melancholic depression to, I guess, shock her back to reality. 

My blood pressure really started soaring when Dr. ZN continued to explain the waveforms, "alpha waves bla bla bla. Beta waves bla bla bla" while Elaine was crying her eyes out. Her depression started after her husband had a disabling stroke and she was left with all the responsibilities around the house. So she was forced to retire and proceeded to be his full time carer for a solid two months until she literally felt inadequate, incompetent and hopeless. Eventually, her feelings of inadequacy lead her to lose touch with reality. 

I was praying someone would shut Dr. ZN up before I broke his neck, because at that point I didn't know what was holding me back. Finally, the mental health nurse approached him and said "excuse me... I hate to be a pain in the ass but your patient is really unwell. Maybe you should go over there?" he smiled sarcastically and reluctantly agreed. 

Then G, one of my colleagues, proceeded to explain how he met Elaine and thought the point where she was struggling in bed while they were sedating her was a good time to explain her history. I felt J was also quite disturbed by what happened and we both shot G a look, and he didn't understand. 

Could you shut the fuck up? 

"What? I'm trying to explain her case to you!"

It's really not a good time.

"Yeah, G, seriously. Just shut up."

G, baffled, walked away from us and sat down to read Elaine's notes. 

At that point I needed to leave the room. I was holding my tears back and then Dr. ZN looked at me from across the room and said, "You look a little detached!" with a big smile on his face. That was when I walked out of the room. 

I locked myself in the bathroom and I was either going to break the mirror, cry, pass out or wash my face. So I did the most appropriate of those choices. After drying my face with some paper towels, I walked outside to find Dr. BB. He saw me and it wouldn't take a Psychiatrist very long to work out how I felt - my face usually does express my feelings quite well. 

He tried to pull me aside but I said I wasn't comfortable talking about anything there and then. He agreed, and said that we'd see a few patients and then we'd have a short meeting. 

J & I went with Dr. BB to the emergency department where we had a call from one of the doctors working in Psychiatry (a Career Medical Officer - someone who doesn't specialise but works their career in one speciality) to review a patient he was asked to see. He described Rowena as having anti-social personality traits and he wasn't keen on admitting her to hospital. After a few minutes of chatting to her, it was clear she had grandiose delusions, pressured speech and flight of ideas. Yes, Rowena might have had anti-social traits, but more importantly, she was really unwell.

Dr. BB asked the CMO to sedate the patient and admit her involuntarily into the mental health ward. When we went back to the ward to see more patients, Rowena was brought in by security personnel with no sedation, trying to wrestle herself free. We were both baffled. Why wasn't sedation given? Patients in mania are usually quite distressed and for the sake of harm-minimisation, this lady needed medications to calm her down.

It was a hectic morning and it felt as though it couldn't get any worse. Luckily, it didn't.

I ended up with Dr. BB in his academic office to present a case to him and to get feedback from him regarding my rotation. One could always present cases better, but I felt relieved that he passed me - he's a hard examiner... even if it was a practice run.

He then asked me what happened in the morning. I got worked up and angry about how patients were treated by Dr. ZN. It felt like I was throwing the words at him. By the end of it, Dr. BB was shaking his head in disgust.

I always tell junior staff to introduce themselves, be polite and respectful. They just don't seem to want to. There's not much else I can do other than to tell them. 


"But you're a consultant. Why don't they listen to you?"

I don't know. It's more prevalent among our overseas colleagues. 


"Perhaps it's because your feedback doesn't hold the gravity with them as it does with us"

Could be. 


There was a short moment of pause before we exchanged a smile.

"How do you cope with the things you see everyday?"

Mostly by speaking to other consultants and with weekly debriefs with the head of department. It's very important to share your encounters and thoughts on clinical situations with senior colleagues. 


"I'm having a lot of trouble seeing the patients in Psychiatry so far."

*Pause*

I really think that if you don't share what you see, you will lose touch with reality.

It felt like a bomb hit the building. "So what? People become psychotic?"

I do think so. You surround yourself with patients who have delusions, hallucinations; symptoms and signs that convey their reality is distorted. Eventually, anyone would find it difficult to separate all the stories from reality. It's very difficult to stay objective, particularly in Psychiatry.

We spoke a little longer to debrief but I could've stayed in there for an hour. But the bottom line was drawn well before I walked out of the room.

There is always a chance our reality will become distorted.

So I may very well still be riding on a roller coaster... and that may be real. 

Insight

We often forget how traumatising it is for patients experiencing their journey in healthcare. We are part of the hospital system; we breathe it, feel it and keep it alive.

Sometimes I daydream about a hospital in itself being a myriad of organ systems; a patient micromanaged by an overwhelming power (administration) in terms of providing life support (funds, employees) and this delivered through transporter proteins (Medical Teams), which release transcellular messages (investigations, management plans) with paracrine function to other local cells (Healthcare Professionals). Through this extensive, complex process, one reaches cells that are dysfunctional (Patients) and aim to reverse or control the damage (Disease) in the hope of restoring their function in the role of the whole (Community).

It is not uncommon for medical professionals to go about their everyday work and yet feel detached. Both as a subconscious coping mechanism and as a way of minimising their workload. And through these barriers, we set up not only thick skin resistant to the everyday tragedies we encounter, but also distort our senses: re-setting the "normal" range such that certain news that was considered significant (example 1: you need your gallbladder removed), life-altering (example 2: we need to remove your breast and most of your armpit to catch this cancer) and terrifying (example 3: there's only one solution: we remove your rectum, anus, vagina and bladder. It's the only way to increase your life expectancy) have now become benign, mild and moderate.

And the process is progressive; continuous such that the normality is continuously re-set as clinical experience lengthens and our insight deepens. This brings me to the situation that provoked these thoughts within me.

Matthew, a 28-year-old gentleman, was brought into the Emergency Department by Police under Section 22 (i.e. as an involuntary patient because he was considered mentally disordered). The reason he was brought in with his wrists clamped together with cold steel was a high-speed chase. We weren't told why Matthew was running, or what preceded the hot pursuit. But we did know we needed to see whether the police were correct about his mental state.

That's about all I knew about Matthew just before the nurse mumbled Bipolar Disorder at handover. The clinical picture was a little clearer now; he must've been manic. At that point, it was time to meet him with the Psychiatry registrar.

He was very agitated about being in the mental health ward. I'm being held against my will. Why can't you understand this place is not the best location for my recovery? Why can't you understand? What's your problem? Why are you looking at my hands? You keep getting distracted!


It escalated for a short time and I was sure that Matthew was going to get up and start throwing chairs around the ward, but luckily he didn't; another patient not too far away already volunteered his attempt at sharing a psychotic breakdown and successfully did with four security personnel and a nurse. After a few weeks in this ward, such events seemed not-so-dramatic.

I couldn't help it... I had to ask the registrar. Why did you keep looking at his hands?


"Because I was afraid he was going to get physical. Also, he had complained about upper limb weakness and paraesthesia earlier today. I was grossly assessing his movements. Seemed quite normal to me. What do you think?"

Uh.. I don't know.


The registrar decided to see Matthew a few hours later with the consultant, along with his family. I could sense that he was very restless and agitated, but not in a 'mentally disordered' way. He seemed rational and as the Psychiatrists say, "no formal thought disorder".

Matthew's parents and younger sister attended the meeting to discuss the issues around his admission into the mental health team. Apparently for the past few weeks, Matthew had been demanding his family sit and listen to his teachings about computer specifications, why they should purchase electronic goods with highly specific and elaborate criteria. It got to the point of happening every day, for at least several hours.

What do people do when they get home from work? They walk through the front door, take their shoes and socks off, get into their comfort zone and chill. Well, Matthew's family wasn't allowed to do any of that. They had to walk through the door and listen to his teachings. Luckily he had a job as a night-filler at the local supermarket and the family had some hours of peace late at night, which they used happily to rest and recover.

They wanted Matthew to continue staying in the mental health ward involuntarily until his agitation and from what we understood clinically, his mania, subsided. Dr. BB agreed and we asked Matthew to join us to discuss what we thought. The tricky part was to ensure Dr. BB made clear it was his decision to keep Matthew in the ward, not his family's.

Dr. BB - I don't think it is safe for you to leave just yet, Matthew. 


Matthew - Why? I don't see any reason for me to stay. This place is destructive. You're holding me against my will. How could you possibly believe this place is doing anybody any good? You can't smoke, you can't socialise with the other people. There's nothing to read, no access to the internet or phone.

Dr. BB - What would you like to do?


Matthew - I would like to go home where I can smoke, spend time with my dogs and cook some dinner for my family. I want to be able to do the things I normally do to lower my stress. But you can't do that here.

Dr. BB - What can't you do?


Matthew - You can't smoke, for starters.

Dr. BB - We have nicotine patches. I would be happy to organise them for you during your stay here.


Matthew - Mate you know better than me... There are twenty addictive substances in a cigarette. Nicotine patches replace nicotine, but what about the other nineteen addictive chemicals? Do you have patches for them too?

*Silence*

Matthew - This is damaging to me. I don't want to be here. I'm being held against my will. How do you think this environment is healing? There's nothing healing about it. The people are really unwell, the nurses don't give a shit and it takes half a day to see a doctor about anything. It's no different than incarceration.

Dr. BB - I understand. There's nothing I would want more for you than to let you go and enjoy everything you normally do. But -

Matthew - What about my job? I just signed a contract obliging me to work full-time for next twelve months. How can I call my boss? How can I keep this job if I just got this contract and I'm asking for leave? Would they let you do that here?

*Silence*

Dr. BB - I think it is important you stay here for the rest of the week and then we can review you. Once I'm convinced that you're better and your agitation has settled, we can think about granting you some leave. 


At this point tears started trickling down Matthew's face. He got up and stormed out of the room.

I couldn't help but feel sorry for him. Although he was mentally disordered to some extent according to the team, he had arguments that were hard to disagree with. How can cigarette addicts control their mood, agitation and attitude well without their regular consumption of smokes? Is it not true that being confined to an environment crowded with people who are also mentally disordered is detrimental? How can one argue with his points? The consultant certainly couldn't.

Matthew's family agreed to his stay at the mental health ward at least until the end of the working week. It didn't seem he had blamed them, but he sure wasn't happy and I think that's appropriate. Nobody would want to be detained against their will - it is a violation of the basic principles of freedom.

It was a dilemma. Did he have good insight into his illness? He seemed to be aware of what had happened and he was able to describe his arguments meticulously. I didn't want to let this go... I promised myself I would bring it up with Dr. BB and when the time came, I did.

Me - Matthew was actually quite reasonable, wasn't he?

Dr. BB - How so?


Me - Well, I don't think this ward is very healing. He is right in being upset about not having the right to smoke, not having access to the things that usually calming him down. Do you really expect him to get better?

Dr. BB - I do think with time he will settle, particularly with medication. 


Me - What about the nature of his recovery?

Dr. BB - Yes, I see your point. What can I do about it? I don't think he is safe to be discharged. 


**Silence**

Dr. BB - I agree with you. This is not the best place for his recovery, but until he settles down, I don't have much else I can do. And I also think the family needs some time off. 

Although it's sad and unfair, Dr. BB has a responsibility to ensure the safety of his patients before they can rejoin the community, just like every other doctor. At the same time, he has to go home knowing everything he has seen everyday and be a "normal" husband, father and friend to many other people. I really wish it was as easy hanging one hat and wearing another. At the same time, I don't want to wear armour thick enough to appear dismissive the patients and not too thin to become so attached it overwhelms my family and personal life.

For all I know, Matthew was intact. His reasoning and rationale were convincing and it was hard for me to contain myself listening to him because the tragedy, for both Dr. BB and him, was that he was right.

Barriers

I'm sitting up in my bed right now thinking about the year that's just gone right by. It feels like yesterday I was anxious about starting my clinical years in medical school; now I'm but a few short weeks away from being a final year student. Do I feel competent or ready? I'm not sure... Probably not.

My window's open and I can hear the rain, drowning out the sound of cars flying by and the muffles in the house next door. It's always been cleansing for me to hear rain. Right now, it seems that this whole year is being washed away; some experiences I will never forget and others I most definitely want to.

Tomorrow morning is my last examination of the year and I cannot wait to put it behind me. I am sick of revising, taking new notes, looking for old ones, double-checking what I've learnt and testing myself with questions. I'm aware that one little test Faculty decides to throw at us with its wrath of 70 questions in 90 minutes on Psychiatry clearly doesn't suggest any form of competence other than adequate memory recall. It almost makes me feel like I'm taking an elaborate mini-mental state examination, testing things that we have acquired over the past 8 weeks in this rotation.

But that's not where all the fun lies. My supervising specialist insists that I attend on Friday morning, which means I still have a final day in the ward that I have come to dread. It's not so much the patients, but the atmosphere that I despise. Every time I walk through the electronically locked doors, there's a scent in the air that I can only identify as the mental health ward. I can't put a character on it, but I know it's not pleasant or welcoming in any way.

Psychiatry isn't just a cluster of borderline psychotic people sitting around a table deciding on arbitrary management ranging from couches, to pills and then even to convulsive therapy. Psychiatry does make people better and there is an effort that must be recognised - that the mind and body are inherently linked and must be treated together, in harmony. And until modern specialists and sub-specialists realise this clear, yet controversial fact, I cannot be sure that we are optimising the treatment of any patient under our care in any facet of medical care.

Some people have left Psychiatry saying "I can't wait to get back into real medicine". Others believe that's where medicine truly lies. I have concluded that the majority of patients under the care of Psychiatrists need far more medical care than dismissive people in "real medicine" think. These patients do not have regular contact with their General Practitioners and if they do, it is mainly pre-occupied with their mental health, not their blood pressure, cholesterol, visual disturbance, or headache. And the blissful world of ignorance where patients describe their pain, difficulties with function with an intact mental state, where their coping mechanisms are intact, are where people who enjoy "real medicine" want to take cover. Don't tell me about your feelings, just tell me when the shortness of breath started. 

Patients with mental illness really are the monument of medical neglect. The profession has dismissed these poor people as annoying and difficult.

Yet here I am, reflecting on the last couple of months and trying to work out whether my preparation for tomorrow's exam has in any way been useful. My doubts are in place and are difficult to shake. But this is a common finding in all medical students, or any insecure studious person who is hungry to justify their efforts in exams. Only, whatever knowledge I've shoved into my brain has been for the patients that I have seen; to understand them to help others like them and also, to keep the gate-keepers of the question bank in the assessment vault happy.

Like most other people in medical school, I need a break. Not only from the hospital system, but from work, from family, from everything that has become a chore. I need to leave this place, to relax and worry about things right before me in a different light.

There's still so much to tell. And in due time, I will share it with you all. Writing here has been one of my greatest discoveries and I really have enjoyed the hours I have spent thinking and reflecting, telling my stories and identifying my weaknesses. To those of you who I've invited to read these entries, I say thank you for checking up on me, for caring and being there for me by reading my work.

I have really enjoyed sharing it with you and plan on doing so for a very long time.

Grip

I've finished my fourth week in Psychiatry and I can't say I've studied much. I haven't been able to revise and I'm still convincing myself that I'm exhausted from the previous exams. Given the assessments are a month away, I would be nuts to believe this thought process is productive in any way.

Speaking of nuts, Psychiatry has been quite interesting. The first three weeks was in the Drug & Alcohol service, where most of the patient population represents a unique and unfortunate minority. This week was my first time in the "subspecialty" known as Consultation-Liaison Psychiatry (C-L).

C-L is a team of doctors and nurses who see in-patients within the hospital system after a medical or surgical team has requested a consultation.

When I arrived on Monday, I was expecting quite a large team and it turned out there was a Specialist, Registrar and Clinical Nurse Specialist. An overseas student interested in Psychiatry showed up as well, but she got bored before the clock hit midday and I was happy to be on my own with the team. Dr. FN was the specialist, though he was a Pain Physician as well as a Psychiatrist. Like most medical students, I too am intimidated by meeting new specialists. To my surprise, it didn't take long for me to feel comfortable in the team.

Dr. FN's manner was absolutely amazing. A man who never addresses a patient by their first name unless prompted to do so, a doctor who asks if it's okay to sit next to a patient and a specialist who could not be more polite. I watched in awe as his questions were comfortably received by patients and his very presence had a soothing quality. He explained concepts to patients and asked them very personal questions, but apologised in advance if he felt the question was sensitive. He, like Dr. JP in my O&G term, restored my faith in the medical profession.

Seeing in-patients with new-onset psychiatric symptoms, or patients with chronic psychiatric illness was quite a change from the Drug & Alcohol department and the spectrum of illness was quite different. The first thing I picked up quite quickly was how ridiculously ignorant the medical and surgical teams were when it came to mental state, except for the Geriatric teams.

One patient, Mr. AK, is a 29-year-old gentlemen with known treatment resistant Schizophrenia who presented to the emergency department with constipation, which later the Acute Surgical Unit (ASU) labelled as a small bowel obstruction (SBO), probably due to the effects of clozapine. One of the important management aspects of SBO treatment is to ensure that the patient no longer eats or drinks (ie Nil By Mouth - NBM). Therein lied the problem - how was this gentleman to receive his clozapine if he could not take his tablets? And unfortunately this drug is not available in any other form. They decided to start him on olanzapine, another medication but definitely of lower potency. Anyone who's done any form of Psychiatry knows if a patient is on clozapine, that this patient has already been on several medication regimes previously, which have failed. However, let's not forget about his SBO and all the excruciating pain that accompanies it. So the surgeons didn't know what in the hell to do, especially since their knowledge of pain-relief medication is limited.

They requested a consultation from the Acute Pain Service (APS), which was a team composed of an Anaesthesiologist, Neurosurgeon and a number of other doctors. After they saw Mr. AK, and given his particular history, they decided that opiates were not the best option. So they decided to give him Ketamine.

I told this story about a dozen times to my colleagues and the commonest response I got was: Ketamine makes a normal person psychotic!

So one can imagine what it did to a patient with treatment resistant Schizophrenia. He developed florid psychotic symptoms and before the surgical team realised what the hell was happening, the C-L team responded, calming poor Mr. AK down with a cocktail of anti-psychotics and sedatives.

Before we knew it, we realised that his psychosis was under control with an aggressive combination of medications... I'm tempted to call some of them tranquilisers.

2 weeks later, his bowel obstruction didn't resolve and the surgeons had no choice but to start him on total parenteral nutrition (TPN), which is nutritional replacement. It pretty much means that someone needs to be fed their three meals and a few snacks a day through a line that's been inserted into a large vein very close to the heart.

We were doing rounds in the hospital with our inpatient list in C-L and we ran into the Anaesthetics Registrar part of the Acute Pain Service, who told us that Mr. AK ended up in the Intensive Care Unit due to an infected central line.

So this guy came to emergency with constipation. The doctors that accepted his care as their responsibility decided to keep him nil by mouth and by doing so ended up exacerbating his schizophrenia and eventually leading to his admission to ICU for a fucking cause that was none but our own.

It's so tragic how we can fuck up someone's situation so quickly, amplifying their pain, their agony. When I tried to express these thoughts to my colleagues, the answer I got was "that's why you have consent forms" - fuckers.

Stay out of hospital. There is a reasonable chance you can get worse well before you get better.

How do we live with ourselves? How do we go home at night?

Moral Commitments

Why did society appoint the title of 'Doctor' to medical practitioners? Some years ago I came across a book describing the meaning of the word 'Doctor' as 'Teacher', where patients were educated by practitioners about illness, how the medical world has come to understand illness and the possible remedies available. 

In the olden days, the relationship between doctor and patient was paternal. The doctor would simply instruct the patient how best to approach their illness and essentially make their management decisions. In today's era, where such a large of volume of information is available at the click of a mouse or tap on a touch screen, patients have become the central decision making body, along with their family and friends. If patients do not have the insight or autonomy to make informed decisions, a public body may be appointed to make decisions on their behalf. No doubt there are hundreds of pages of ethical discussions surrounding the concept of informed consent and decision-making on behalf of patients, and I would be beside myself if I thought for a moment I understood the depths of those discussions. 

However, what I have noticed is the lack of education that patients receive from their doctors. And to sit in a lecture and be taught that "psychoeducation is a fundamental component of a patient's therapy" as a senior medical student alarmed me. Students can get lost in all the dimensions of disease, their epidemiologies, risk factors, aetiological theories and the various management algorithms that are available in the large arsenal of pharmacotherapy and surgery. 

So then how are we to help our patients if we do not educate them? It is very interesting to interact with people from such a vast array of experiences, education and careers. To educate them about their illness is a privilege in itself. But patients continue to complain about the lack of education they receive, the counselling they long for and ultimately the respect they deserve. 

Ironically, doctors get frustrated with patients who walk into the clinics with 10 pages printed from Google saying that "Cranberry juice can effectively relieve symptoms of incontinence" and are inflamed when they are asked "but why doesn't this work?"

This brings me to something that happened at work last Sunday. It was quiet in the morning and little did I know the afternoon was going to be chaotic, but on I went with my morning with some tea and procrastination. The phone rang and on the other end was a patient who wanted to re-schedule their appointment. The study was for a CT Abdomen & Pelvis, which more often than not requires contrast (ie dye to highlight either the gut, or the blood vessels). The receptionist who scheduled her initial appointment told her about the oral fluids that would highlight her bowels, but did not mention the injection for the blood vessels. So when I explained that aspect of the study, Abigail was rightfully shocked. She calmed down after I answered some of her questions. At this point in the conversation, I was a radiographer and she knew nothing about my medical education. 

She decided to ask me "so why do I need this study?" 

Has your doctor explained why you're having this done?

"Well, I just moved up here and my friends recommended this GP who's apparently very thorough and I told her about my grandfather dying at 93 from bowel cancer and she decided to order a blood test. She called it a Ca 19.9, which was slightly elevated and then she did it again and it was even more elevated! She asked one of the other GPs and they recommended a colonoscopy but she thought we'd start with a CT scan."

I understand. 

"But why is she ordering a CT scan? What's that going to show?"

A CT scan is a 3D imaging tool that shows us the anatomy of your organs in a particular area, in this case your tummy, from the bottom of your chest down to the bottom end. Perhaps your doctor feels that this might show something that might explain the abnormal blood result.

"Okay. If this is elevated, does that mean that I have bowel cancer?"

Not necessarily. 

"But it's elevated. Why did my doctor order more tests?"

She may very well be thorough and wants to be aggressive to look for things because of your family's history of bowel cancer. 

"So that means if there is bowel cancer, the CT scan will pick it up?"

It may well pick it up, but there is also a reasonable chance that it might not.

"So what happens if the scan is normal?"

Well, it may be that she continues looking for the cause of your abnormal blood test.

"You mean a colonoscopy?"

Maybe. I'm not sure. 

"So if I don't have bowel cancer, why is this blood test abnormal?"

That's a good question. It could be that the blood test is slightly elevated, but have you ever had this blood test before?

"No."

Well how do you know it wasn't elevated 10 years ago?

"I don't."

Exactly. A pathology laboratory determines a normal range by getting thousands and thousands of results, applying all sorts of fancy statistics to them and look at what the most common numbers are in people that do not have illness. So it could be that you are the lucky one that has a slightly abnormal test but that's normal for you but outside the norm in the majority of people. Does that make sense?

"Yes. But it could also mean I'm the unlucky one walking around with bowel cancer at the age of 40." 

Maybe. But I'm sure the doctor asked you some questions about your bowel habits?

"Not really."

Okay. You do realise I have over-stepped my professional boundary about twenty minutes ago?

"I'm aware. But please help me... I'll keep the information to myself."

Have you experienced any change in your bowel habits?

“No, they are regular.”

Okay. Have you lost weight recently?

“Yes I have. I exercise regularly but 3 months ago I broke up with my partner and have recently taken up smoking. I also haven’t been eating the same since. I’ve lost about 6 kilos since we broke up.”

I understand. It could very well be that this weight loss could be due to the impact of the break up on your life. It could also be due to a sinister cause. Perhaps this is the reason why your doctor is ordering the CT scan.

“But I didn’t tell my doctor about the weight loss.”

Why not?

“She told me she had to go. I only spoke to her for about five minutes. But the first time I saw her it was for half an hour. She just had some personal things to do.”

"It won't be long"

This conversation went on for almost an hour, but by the end of it, Abigail was quite happy that her concerns were addressed. I was happy to talk to her given that work was very quiet that morning. I was also saddened by the fact this poor lady had been in such psychological distress about her abnormal blood test and the underlying reason for this was her doctor’s lack of commitment. The GP obviously had other [personal] commitments, which to some extent is understandable. If it is encroaching on your ability to see your patients and even worse, if it is denying you the ability to develop a therapeutic relationship, then I don’t see the point in having professional commitments. 

Saturdays

The last couple of weekends have been very intense for me in terms of work, driving and meeting people. Unfortunately it has come to the point where 'catching up' has become more for my concern for people's well-being rather than entertainment. Of course I do enjoy spending time with friends (more with some than others), however after a long day of driving and working, sometimes I just wish I didn't see anyone.

Yesterday I delivered the final lecture in the Radiology lecture series I have presented to the first year medical students. I'm hoping it was well-received and most of them seemed interested. I was able to reflect on the lecture this morning on my way to work with what limited attention span I have when I'm driving and it occurred to me how oblivious medical students in pre-clinical years can potentially be. To most of them, it is mostly about lectures, learning objectives and textbooks; despite the emphasis that patients are in fact the most important component of medical education. There are exceptions to the rule and I definitely was not one of them in my pre-clinical years.

Saturday for the last few weeks has been the busiest day of the week - I do almost 2-3 hours of driving, meet a few people and seldom make it home for dinner. But when I talk to my good friends, Saturday is a day to sleep in, enjoy a hearty and hot breakfast with loved ones and think about things such as the weather, music and sport. Saturday is for going out, enjoying a few drinks with friends and sharing laughs over some food. It's also for clubbing, dancing and meeting new people for the curious.

But for me, Saturday is about work, doing favours for friends and family, occasionally eating. I do spend time with friends and family, though sometimes I don't want to. I would love to sleep in and not think about what to do, who to meet and what to prepare. I want to wash my car, pick out all the leaves from under the bonnet while listening to music. Sometimes, I don't want to communicate with anybody. I just want to listen to ambient noise.

When did Saturdays get so busy? It all started in year 4, when my parents decided to send me to Saturday school for developing my language skills in Turkish. So I only was able to sleep in on Sunday mornings, but most of the time my parents would wake me early to have a family breakfast (not that I'm complaining - it's awesome food). That clarified a lot for me - Saturday has been forged in my head to be a day of work or study, unlike most of my friends in school who enjoyed the sleep ins, soccer games and Centennial park. After primary school, it was Saturday high school, after that came work at Harvey Norman and Math Tuition, after that came Radiography.

What about the school holidays? Good question. I spent most of my time catching up with movies, games and the occasional game of basketball with the local kids. What about sleep? Even now, I can't sleep in unless I force myself to stay up, which is useless because I still end up sleeping the average 5-6 hours a day.

I stay up late because I just want time by myself to do the things I want to do, such as play a video game, blog or watch something. I can only do this at inappropriate times of night because that's when people are fast asleep or have established that at such times it is socially unusual to contact people. It's my rebellious way of saying "fuck you Saturday, I'll still end up having time to myself, no matter what I do during the day." Though it is becoming quite old-fashioned and immature, I am still gripped with the decision despite the exhaustion.

As much as I would love Saturday to be a day off and to establish some level of sleep hygiene, it seems that such a wish is out of reach for now, and may just be for decades.

But then again, I'm not the kind of person to sit still. So if I did ever take time off, I would find a reason to wake up early and do something to make myself useful, to use the privilege of having a day to spare wisely.

Please enjoy your weekends and rest assured. As much as I am complaining, I too enjoy my Saturdays.

Unlocked

Internalisation is a process by which genes are activated to change polymorphisms, facilitating the displacement of receptors, channels or substances from the surface to the intracellular space. I probably didn't use the correct terminology to explain the above appropriately enough, but I'm sure you have understood or are familiar, to some extent, with this biological phenomenon.

Our particular subpopulation is prone to emotional and psychological trauma. It might be foolish of me to say, but we often forget that patients are sick; patients need our help. Last week Dr. KF introduced us to Matthew, one of her favourite patients. He was a man who looked 65, but was actually 51. His big, white beard seemed well-maintained for a man who was homeless, had a longneck beer in one pocket and Tally-Ho cigarette paper in the other. His clothes were torn and faded.

Matthew sat with us for over an hour, talking about his experiences in prison (over 5 years for different offences), told us about his relationships, children; but mostly he told us about his addiction to heroin. This man was well read, mild mannered and had a cognition that was intact. There was a significant mismatch between his physical appearance and behaviour; his colloquial language and intellectual descriptions. He took us through how he had organised to continue his addiction through financial means, manipulation of prescriptions and many other facets of his life.

We patiently sat there, trying to make sense of the history and piece his story together but he was a very good communicator. He went from story to story, they all seemed related and he would use one story to explain another story, which clarified another. And we did the best we could to organise the information in order to process it, well before even thinking about presenting it to a senior clinician.

I very much appreciated him volunteering his time to talk to us about his experience. It was clear to me that Matthew was a good person, a down to earth, wise human being who had been through much more than he bargained for. He was introduced to alcohol at the age of 6 by his parents and first started experimenting with illicit drugs at the age of 14, in between reading about Ancient Greece and the components of a Constitutional Monarchy. So then why the jail terms? Why the homelessness?

Being under the influence of any drug distorts the senses. They can create are called positive symptoms (ie experiencing things that are normally absent) and or negative symptoms (ie being deficient in things that are normally present). Matthew had committed crimes of theft a number of times while being "high" on heroin or speed and well, they added up. But he never meant to steal anything. There are times he did consciously to support his addiction and maintain basic human needs such as food and drink (although beer does not constitute a human need).

But what of his health? Does he look like a 50-year-old man? What of his past medical history? Did we ask him about his family history? If this gentleman is an injecting drug user, what are his medical risks? If he uses prescription narcotics routinely, does he experience the side effects? If so, how does he manage them?


Our supervisor drilled us, painting a portrait of the patient's history on the walls with our brain matter. Matthew admitted to having two heart attacks in the past. No follow-up, no regular doctor. But why? If a person had a critical illness, wouldn't they feel the need to present to the emergency department if not their doctor, or any doctor?

Imagine you're the emergency doctor and an middle-aged man presents to you complaining of chest pain for a couple of hours with shortness of breath. After you take a thorough history of his presenting illness, past medical history and all the other biological stuff, you get to the drug and alcohol history and he admits to using heroin regularly for the past 36 years. Are you going to give this man morphine for his chest pain?


Given the way Dr. KF asked the question, the answer was obvious. But the truth is, other people out there, qualified practitioners, do not see it that way. This person could very well be trying to manipulate the system to obtain narcotics to maintain his "high". Such people are dismissed in the emergency room, made to wait hours on end without pain relief; and this was all in exchange for honesty and trust in the medical practitioner considering their complaints.

Can homeless people not have strokes? Can a heroin addict not have chest pain? Who are we to judge them?

It's a disgrace. We ignore these people, avoid contact with them and change direction if we see them on the footpaths. I wanted to help. I didn't want to judge, discriminate, or dismiss. And I hope I never do.

Initially I started writing this entry because I wanted to talk about internalisation. It is fascinating because I do it consciously all the time. I look at my life and the things that should concern me on a daily basis; sometimes I stare at the world around me caving in with the demands I have set up for myself. Then I leave all of that at the automatic doors.

I have been unable to do this in Psychiatry as of yet. As in the movie Inception, we all have secrets and they are locked away in safes, hidden deep in the midst of our thoughts, clouded and distorted by surreal defence mechanisms.

There is a lock that obstructs access to these secrets, which could otherwise be discovered through a door. It is as symbolic as it is literal. We interact with each other (friends, patients, etc) and try to make sense of who they are, their hobbies, principles and morals; perhaps we dig further and find out about their family, religion, country of origin. Over time, we may be allowed to dissect deeper until to us a door is revealed. And there is a lock. Each individual who has had the privilege of being exposed to this door was also given a key unique to them. This unique key exposes to the listener, friend (and perhaps healer) to the mysteries of an individual's vulnerability that [the patient] has explicitly allowed.

Such an intimacy might take years to build. Decades to maintain. Seconds to shatter.

Psychiatry demands instant assessment of the individual. For me, this has been an unnatural experience. I am meant to start my 'examination', or perhaps analysis, from the moment I have obtained consent for the discussion to take place. I must assess their general appearance, mood, speech, thoughts and cognition; and much more. Such things the non-psychiatric clinician takes for granted. It never occurred to me to consider these factors in assessing a person's well-being and I definitely didn't think that such assessments would unlock the door to my own darkness.

So here I am, on my blog, slowly spilling out the stories one at a time.

I have been feeling down most of the day, with intermittent bursts of happiness, easily reversed. So fragile. I didn't go into the Addiction Medicine department in the guise of a 'day off for study and rest' but the truth is, I felt weak. I didn't want to face the patients with the tragic stories for fear that my own insignificant demons in comparison would be revealed in some subtle way to reflect my weakness.

My door is slowly being revealed to those around me, but also to me and I am so afraid of what I might find if I open that door myself. I can only avoid what kind of fear I would be feeling if other people could access it. And there's the catch. I'm in Psychiatry right now, surrounded by people that can analyse my appearance, speech, cognition, thoughts and every other component we are taught to assess in each patient.

So I stay quiet, in the background, occasionally suggesting this or that, trying my utmost not to dig myself a hole.

It's the second week and I really am not sure if I am emotionally ready to face what awaits me tomorrow.

As a person with Surgery in mind as the specialty of choice, I am finding Psychiatry quite frightening and I am beginning to see why surgeons are able to avoid it, ignore it and dismiss it at the times they are supposed to address it in themselves, in their friends, family and tragically, even their patients.

Before 2230

It was my second day in Addiction Medicine and I started settling in after getting to know some of the patients. The typical 'medical student' day in this department is from 0900 to about 1400, but I make a point to stay back as long as I can, to do what I can to help. Thankfully, most of us are doing the same thing.

My wristwatch read 1700 and I thought it was about time to go home and head over to the gym. I have been neglecting my physical health for a couple of months due to exam preparation and a whole lot of procrastination. The phone buzzed and walked over to pick it up. It was Dr. KF, my mentor and now my supervisor in this sub-specialty rotation. 

I was hoping you could accompany the intern tonight on his evening shift in the hospital? He only just found out he's working and hasn't had much to eat. It would be great if you could give him a hand if you're not busy.

I'll be there in 5 minutes. 

Thanks so much.

Dr. KF bought the intern and I some dinner before the shift started. As expected, the pager started piercing the air, prompting us to head over to the wards. We ate quickly and off we went. 

Which wards are we looking after tonight?

Surgical wards and also the medical assessment unit.

The Medical Assessment Unit (MAU) is the place where the majority of the geriatric patients go for assessment prior to admission to hospital. So the patients tend to have a very complex medical presentation with multiple problems as well as Not For Resuscitation (NFR) orders. The families tend to be involved in decision making, if they don't make the decisions on behalf of the patients altogether. 

The first consultation was out of the ordinary - the paediatric ward for some analgesia prescriptions. That didn't take long and we soon made ourselves known to the nurses in MAU and the surgical wards. It wasn't as chaotic as we anticipated and so we took our time taking bloods, inserting cannulas. There was the odd scare - a few hypotensive patients in the surgical ward gave us a fright but after some observation, they were fine.

So far, so good. 


At about 2100 things started to get hectic. The intensity of calls for cannulations, bloods and medication reviews spiked and at this point the intern and I were on separate wards. I can't say I was comfortable with the frequent misunderstanding that I was a doctor and not a medical student. I'm sure the nurses did get rather annoyed with being corrected constantly and in their eyes, if we were wearing shirts, ties and holding a stethoscope, we were no different. Appearances can definitely be deceiving.

It was almost 2200 and we were about to make our way over to the common meeting room where the hand-overs were done. I had the intern's pager and he was at the other end of the surgical ward. I was just talking to a patient about inserting a cannula and the pager went off.

E2 medical student. Somebody paged?


Yes, I'm calling from MAU. Bed 1 has stopped breathing.

And that's all I heard. I put the phone down and power walked toward the intern.

We have a MET Call. 


Fuck. Let's move!


MET referred to the Medical Emergency Team and they are composed of an anaesthesiologist, intensivie care physician, nurses and other team members. We both ran down the surgical ward, waking most if not all patients with our not-for-sprinting shoes and the nurses on the wards weren't phased much; they understood the significance of our haste.

When we arrived outside Bed 1, all the curtains were drawn and the lights were off. MET was obviously not called and I hadn't let the nurse explain that the patient was NFR.

The intern looked at me. What are the components of the clinical assessment to declare a patient dead?


I drew a blank, but quickly composed myself. Dilated and unresponsive pupils. No heart sounds. No breath sounds. No response of any kind to painful stimuli.

Good. We have to elicit them.

After spending a few minutes looking for a pen-light, we went to examine the patient.

He was pale and stiff; his face and neck turned to the right with his mouth open and eyes partially closed. We called his name and there was no response. We shook his shoulder and he did not startle. The intern looked at me as I handed him my stethoscope. He confirmed the absence of heart and breath sounds. Then he pinched the patient's chest, then his eye-brow... there was no response. The pen-light partially lit the room and we looked at both his pupils, completely dilated and they were not responsive to light in any way.

He's gone.

It was the second shell of a patient I had seen. Quiet, calm and absent. I had trouble putting my thoughts together and thought it would be best to just stay silent and only speak when spoken to.

I got home and shed some tears - I wasn't expecting this, but then again, that's my mistake. We are in a hospital. We deal with death everyday. The intern seemed to have no problems with it. It wasn't long before he was talking about the weekend, some facebook competition, karaoke the night before and which girls he was attracted to. Thankfully he was talking to another intern and so, I could tune out from their conversation.

This wasn't the way I was expecting to start Psychiatry, but one way or another, I end up getting pulled into some task, somewhere. And I definitely do appreciate it. Everything is a learning experience and no two patients are the same.

The next day I was tempted to go and see some of the patients we saw over the evening, but decided against it.

I am grateful for this week to be over. We have a lecture or two in the late afternoon and then I am free to relax throughout the night. Some time to myself and distractions with books and lectures is what I probably need.

Seeing some of my friends also made me happy. I look forward to keeping in touch with more of them now that I've returned to the student accommodation. 

Intima

After the very short break, I started back at the hospital, assigned to the specialty I knew very little about. Colleagues had told me it was radically different than 'traditional' medicine and there was little I could do to prepare myself.

Some of my close colleagues didn't think much of Psychiatry, but I knew I had to take it seriously. The patients are vulnerable, and perhaps I am too. It seems to me the art of medicine can truly be elicited here as nothing is more important than establishing rapport and trust in an atmosphere riddled with vulnerability, distrust, doubt and much more. There are few organic (i.e. identifiable) causes of a patient's abnormalities and thus, clinical examination, laboratory investigation and radiological assessment are barely helpful except to rule out obvious, yet uncommon, identifiable causes of a patient's illness. Essentially, the only tool that is useful to organise and understand a patient's complaints is the history (i.e. interview).

I am currently assigned to the Department of Addiction Medicine, which is a subspecialty in its own right as the sub-population is highly unique. These are people banished from society due to their addictions and are incredibly distraught by previous experiences in their lives. Their sensitivity is striking and they pick up on the smallest notions of judgment, condescension and any hint of "I'm better than you, so let me help you." Not that I'm like that at all, but one has to be very conscious of their reactions and responses to the details these patients reveal. We must be empathic in moderation - going overboard may disrupt the rapport and showing little will destroy what structural support the initial impression a clinician gave the patient. This is a critical opportunity for us to practice people's skills and I'm sure we could all use a little of that.

The patients were somewhat uncomfortable and apprehensive. When I took notes, some of them were very concerned about what I was going to do with these notes and I found it difficult to explain that this information may be useful for their care. I'm not sure how they felt about that, but it was clear they weren't comfortable. I must get to a point where I can recall the majority of the history from memory, but that will take a very long time.

Growing up in the suburbs I did, drinking was a normal part of the playground. Young teenagers and their parents drank in the morning, afternoon and evening; sometimes well into the night. When there was no alcohol to buy, they resorted to drinking methylated spirits. Playing basketball around these people made me uncomfortable and the frequent bullying and glass bottle-throwing was not a nice gesture either. So I hated them - these people who drank until they couldn't stand, feeding their children and encouraging other children to join them. My hatred of alcohol use was amplified when I was old enough to realise that my father was a drinker. He had his nights of binge drinking, but what bothered me the most was the fighting. Then the late night self-talk he mumbled to himself, mostly profanity and the slamming of the china as he washed the dishes at peculiar hours. I enjoyed the odd drink of alcohol, but not to the extent that I was so drunk I was saying whatever came to mind and doing whatever I pleased.

High school exposed me to drug dealing in the bathrooms, marijuana use by my close friends and even cocaine in the final years. I didn't take drugs, but it was certainly popular. If I knew my friends better, I could have also known about their obsessive use of anti-depressants. And these memories have resurfaced in the last few days. Well, I guess that's slightly inaccurate: my father still drinks about 1-2 bottles of wine per night, every night for years. Every time I stay with my parents, I get angry and shut myself in my room, watching movies on my own or playing computer games until I was tired enough to sleep quickly when I went to bed.

I didn't like what was happening around me and it was easy for me to judge people. Thankfully I didn't have these thoughts and feelings when I started the rotation, and they haven't surfaced in the clinical setting as of yet. Every patient I have spoken to has mentioned sexual, physical, verbal or psychological abuse by either their spouses, children, parents or siblings so far. The very people that were supposed to be supporting them were the people destroying them.

Interestingly, all the patients I spoke to this week were self-admitted. I admired their courage and strength. They knew they couldn't survive any longer out in the world of pain, damage and abuse. At the same time, they wanted to get over the addictions they developed to numb the scarring and agony. Some of these people were disadvantaged since they were born, others had significant events that changed the course of their lives.

We as students, clinicians and professionals must be very careful to help these people through such a very delicate time in their lives and I hope we are able to make them feel safe, comfortable and eventually, create an atmosphere where they can speak to us about the things they like.

Our past will re-surface and we must be careful to maintain our own composure while remembering that it is the patient that is the strong one - they confessed, admitted and presented for help. We're still just coping within the barbed-wires of defences we have set up in our own minds.

Recovery

I woke up 2 hours later than I planned this morning, but I feel replenished and more motivated to study. This is a two-fold response: the first is that the sleep was all that I needed and the time that I've lost is increasing my stress levels. It's probably this coffee I've had in the morning as well.

Tribute to Nikola Tesla

So now I just need to go through the motions and revise, learn and research, just like the last two days.

I need to make the most of what time I have left and remind myself that it is alright to actually have a break from time to time.

Truthfully I'm not sure what kind of questions they will be asking in the upcoming examinations, though I am worried that they will be difficult. I'm also concerned because there may be discrepancy between what I am actually learning and what is going to be in the exam as I am using the USMLE preparations.

This is the first time I have used these resources and I must admit, they are brilliant. I think someone really needs to the sit the Faculty down and play a few of these to show them how to teach medicine. We are very behind, with most of our teachers being humble and lovely volunteers and for that I am ever so grateful. What worries me though is the fact that they spend most of their allocated time discussing their research, regardless of how relevant it is to our clinical practice, modern care and current medical and surgical protocols.

There is no point teaching me about what is to come if I don't know the ins and outs of the current practice. These USMLE preparations have got holes as their epidemiology will be different to the Australian figures, but I am hoping I can cover these holes on my own at the end of all my revision.

We will see how today goes. I don't have as much time as the last two days, but I am feeling happier than yesterday. It felt like I was a mess last night.

I'm confident that the sparks of this morning can carry me on through to Sunday evening. It was a good reminder to me that my body really needs rest after such a barrage of information, even if it is just revision.

I can only hope everybody else is looking after themselves and are studying well too.

Preparation

Study has been productive since yesterday and that's good. My issue is that it's only the second day of study and I'm already lapsing in and out of inactivity. One minute I'm nailing it, the other minute I just don't want to continue. Knowing that I need to means that I can't enjoy any leisure activities including exercise.

So far it's all about the medical exam. Formal study for the surgical exam is at an all time low because the discrepancy in knowledge expectation is driving me absolutely nuts. My understanding of the 'Core Curriculum' is that all of it could really be summarised by saying just read and learn all of Tjandra's Textbook of Surgery. It's a nice textbook, but so summarised that it feels like the author was slapped a few times with a mallet before he wrote it. Most of the enthusiastic surgical students have already read it, some have summarised the entire textbook (scary). I'm stuck between reading it and correlating its 'chapters' with Bailey & Love's Short Practice of Surgery. That book's title is so deceiving; Short Practice. The authors must have had a good laugh when they named their baby after measuring it to be several inches thick.

I'm stuck in a rut. I want to study harder but I can't process more. I need rest but I want to study. I try to rest but I can't because I'm guilty.

It's all very scary and I hope by Friday I'm at the point where I don't care. At this stage, I am caring more than anything else. I just need to keep persisting. It can be so demanding sometimes.

I am far from ready. These exams will be the hardest that I have ever written and the worst part of it is the lingering 20% failure rate in the O&G term just about a week ago.

The thing that's really slapstick hilarious is the fact that I'm almost 75% through this program and apparently completion of this program (mind you most of it is self-directed) correlates reliably with medical and surgical competence. Supposedly my opinion will be empowered with authority and I will be able to prescribe medications, counsel patients and break bad news to their families.

All I can say is that I have a long way to go and I'm far from ready for next week's assessments.

E-mail

The O&G co-ordinator told us that the results of the OSCE and written assessments would be available on Friday morning. Most of us, if not all, held our breaths as the e-mails started trickling through. We were all nervous. Coming out of the OSCE knowing that we had missed large chunks of information was not reassuring.

I had arranged to study on campus with my friend CA and I got a call from one of my colleagues, JJ, that the e-mails had been sent. I passed! Thank God! and I was glad she did. The issue for me was whether I passed.

My pulse started racing and my mouth was dry. Before I knew it, I was almost breathless and I couldn't hear the music over my heart pounding in my chest. In my state of sympathetic overdrive, I decided to pull out my laptop while I was driving after I switched on my wireless modem. After the symbols of connectivity showed up on the screen, I opened Entourage, the e-mail client. After a few moments, it grunted stating there was no new updates. At that point I realised all the beeping was from the cars behind me.

I pulled the car over and restarted the modem. Maybe its a connection issue. Again, grunting from the e-mail client. I decided to go through hotmail and sign in - after an agonising two minutes, it signed in and there was nothing in my inbox. My blood pressure must have been through the roof.

There was little choice - I called the co-ordinator. The internet has been down for about thirty minutes. I'm sending out the results one at a time. I'm sure you'll be fine. That sort of reassurance isn't really reliable, especially in my state of mind. I thanked her in my breathless state and started making my way over to meet CA.

Drenched in sweat, I saw CA waiting there for me and I explained what had happened. She had a similar experience with her examination results. After drowning my anxiety with 600mL of water, we spent half an hour trying to find a quiet place to study. All the library rooms were booked out and there wasn't much we could do other than study in our anatomy museum - a very peaceful place.

After an hour of watching some lectures, I checked my e-mail again and it read Congratulations, you have successfully passed all the summative assessments in PWH.

I was able to relax now. It wasn't a "hooray!" because of all the tension that accumulated over the past hour, but indeed it was very relieving to hear that news. We exchanged phone calls and messages with results; so far it seemed that we were all satisfying the Faculty's ridiculous assessments.

Friday ended up being nice, studying and chatting with CA and spending time with my girlfriend over dinner was a magical way to spend reminiscing four and a half years of our relationship.

I made a few phone calls after work today to some of my friends to see how they went in their exams. SW just finished Psychiatry and he too had passed. However, he knew of at least 9 people who was unsuccessful in the O&G OSCE assessment. By that time on Sunday I had already heard of a few people failing as well and that meant about a dozen people had to re-do the OSCE at one of our metropolitan hospitals.

The problem was that even colleagues in the rural schools had to travel to metropolitan Sydney to attend the second round, meaning that they would lose hours if not a day of much-needed study for the exams just over a week away. This ridiculous principle also applied to colleagues that were unsuccessful in other specialty assessments.

Of course it would be too courteous of our Faculty to schedule the re-sit assessments after the week of final examinations. That would obviously make so much sense that it would be inconsistent with their repertoire of stupidity and protocols of idiocy.

My description of how I feel can only be described as bittersweet: I'm relieved that I have passed my speciality assessments but depressed about my friends and colleagues having to re-sit for the second time just before the final exams that determine whether we are eligible to be final year students. The final assessments are also very difficult as they more than likely examine disciplines that we have not been exposed to at all, meaning that certain disciplines that we may have studied are not relevant. But that's a whole other story.

All the best to those having to sit the second round assessments. I hope they pull through. I really do.