Pop

Do you ever get the feeling that you wake up encased in a bubble of happiness reinforced with steel? Getting out of bed with a lovely smile, admiring the clear blue skies outside your window and wondering nothing can make me feel bad today.

Well, I was blessed to have a few consecutive days of happiness in that fashion where I was catching up on sleep and able to not feel constantly frustrated with other people and also have the patience to smile while stuck in a traffic jam, though there were exceptions.

This weekend, it felt like almost all the potential forces around me did what they could to bust what I had. My girlfriend has been having familial issues and has been rightfully stressed about her academic commitments for a few weeks. So I do what I can do to reassure her and help her feel confident about her decision. Reminding her that she is capable of doing anything she likes feels like mission impossible occasionally. This weekend was one of those occasions. At the same time, my parents decide to have an argument on what happened overseas over two years ago and our relatives there keep calling back pleading for help, despite the fact that they stole whatever savings my parents had left.

On top of all this, I decide to leave my girlfriend alone to work and study - to be productive and I met up with one of my closest friends for lunch. We do enjoy subjecting each other to teasing and the like, but yesterday he truly went too far. He interrupted me and gosh am I happy he did, when I was just about to tell him get the fuck out of my car.

Then, my ex-student from 3-4 years ago gives me a call telling me she's too busy to meet at my recommended time so I can advise her brother about medical admissions. So that slot in my schedule allocated to whom I thought was appreciative, now is filled with annoyance.

Further, I get no study done this weekend, which is driving me insane and I forgot the data-entry material at work when I left yesterday.

After messaging my girlfriend, expressing my concerns and worries toward her mental health as well as her emotional wellbeing, she stops responding to me. So when I call her at midnight before I sleep and tell her you've been out of touch, the response I get in return was: I'm sorry I'm just too busy.

The world can seriously be fucking cruel sometimes. That it punishes people that try to stay optimistic and brings them down to their depressed state.

It really breaks my heart.

Storm's Coming

That week off seemed so long ago but for a change, I am not complaining. My first week in General Practice has been fascinating, though my exposure has been rather limited - one and a bit days. The remainder of the time we have been attending workshops and lectures, most of which have been fantastic.

In our short break, I was able to catch up with some of my good friends in medicine. Of these, a considerable number of them had done Psychiatry - a field that baffles my mind. An area that can offer therapy through abrupt means, or no therapy at all. That is of course a judgement rather than a fact, but that is really how I will feel about it until it's my turn to plunge into its complexity. However one of my friends did mention a fact I didn't know - it's very easy to get onto the Psychiatry training program. In fact, one may apply directly after medical school without internship or residency. I was very surprised to hear that.

Well it confused me. I started thinking about the first time I attended a careers expo and the College of Psychiatrists handed out booklets, stickers, pens and DVDs. This was while I was in first year and well, I thought I'd give the DVD a go, seeing as though one of my heros in high school was Dr. Hannibal Lecter - yes, I'll explain that later.

So the DVD showed a few registrars explaining how good the pay is and the hours being very friendly. Showing them with their stethoscopes (God knows why) and ties with no pagers attached to their belts. Big smiles and enthusiastic tones.

Remembering the moments I wasted watching that stupid DVD got me thinking about the Colleges and their marketing campaigns. At that point, the penny dropped. What sort of marketing does the College of Surgeons have for medical students?


The College of Surgeons do not need a marketing campaign. They have waiting lists long enough to supply the third world with enough enthusiastic doctors for at least half a decade. I then remembered at that same careers expo showing up at the RACS desk, lining behind about eight people. When I finally got to the front and met the only representative working there, a Vascular Surgeon, he looked at me and waited impatiently for me to ask my questions. He was already irritated with the guy before me, but that's another story. How do I get into the College of Surgeons?


Everything you need to know is in this booklet. Thanks. 


So I walked away with a booklet printed on some respectable paper that was but a few pages. There was no registrar quotations, any suggestions about hours of work or pay. Only the requirements for admission, the process of application and factors that influence the application.

Now it was obvious. Why would they need to advertise? No, they have plenty of applicants.

This all brings me to the purpose of this post. CH, one of my good friends since the first year of medical school, decided last year that he wanted to devote his life to Orthopaedic Surgery. Now, I am sure a lot of people make that [temporary] life-changing decision, only to realise that they are on the brink of suicide well before they get admitted into the training program. But CH was different - he was 28 years of age, about to get married and ready to serve humanity, like his father did as an Ophthalmologist. He appreciates my passion toward General Surgery and he teased me all until last week. This is a man, a friend, who spent what little holidays we had at the end of last year as a volunteer in the Orthopaedic Emergency operating theatres in Southeast Asia, helping those in need as a surgical assistant. He loved it, couldn't get enough of the involvement, the life-changing interventions and I am sure to this day that it influenced his decision to pursue Orthopaedics ever more.

But then I got a message from him last week:

Just had my first proper day in theatres on a General Surgical Service... 7 procedures, scrubbed on six including the final for the night a crash laparotomy, right hemicolectomy and anastomosis for ischaemic bowel... With a boss who wanted to teach... It was awesome. Thinking of you and wondering how you'll cry when I snag your spot on the Gen Surg training scheme...


At first I thought that was a great message and smiled. Then I realised that it was true. With his reputation and passion, which is well and truly beyond me, he could take my position in any training programme. And he isn't the only brilliant star out there.

How sad that our futures are determined not by our passions or goals, but by the hands of the few that classify us as competent. Albeit necessary, it makes me feel like getting into the College of Surgeons is almost asymptotic... I'll get closer and closer, but never get there. Sometimes it feels like no matter how much you sacrifice, how hard you work, what you sacrifice and how detached you are from your family and yourself - you will be unsuccessful because more is required of you.

Yes, the process of becoming a Surgeon must be convoluted, complicated and challenging... the perfect ingredient for a competitive environment that is the application process. I can only hope that doctors, some of the most intelligent, capable members of today's society, do not find a way to pick the locks that prevent them from practicing unsafely. And if they do, I pray they'll ensure that the lock is replaced through the appropriate channels.

Deception

Medicine is saturated with facts, algorithms, regimes and protocols. Within each sentence, table and graph lies the answers to what we seek in the best interests of the patients under our care. Competence may be defined in this context as the ability of synthesising a clinical picture - the patient's presenting complaint and its history on the foreground; their past medical history in the background along with family, social life and profession in between. Integrate this picture with a sound understanding of anatomy, physiology, biochemistry, pharmacology, pathology and other critical topics of medicine... and you have the ability to understand the patient's situation as well as recommend a management plan that will hopefully help them get to their baseline, whatever that may be.

It all starts with clinical medicine - taking a comprehensive history and based on that, performing an examination. Essentially at the end of all this, one comes to a conclusion and investigates this conclusion to prove it and or exclude other causes.

But all of the above makes a great assumption - that the patient is telling the truth. It also assumes that the patient is less knowledgable than the doctor. One need not look further than Addiction Medicine for these 'break-downs' of classical medicine.

I was at a General Practice seminar today, where one of the activities was the video-recorded role playing. Two students are selected, one taking the role of the doctor and the other being the patient in the context of a complex consultation.

A good friend of mine, Jay, was playing the doctor and a colleague, Em, was playing the role of the patient. The patient began the consultation by stating that they require a script for Valium; a known drug of addiction that is common in the community. It is also used as an anxiety suppressant and is obviously quite effective. Jay explored the reasons why Em required the Valium and the responses were that she was a single mother of two children and needed stress relief. She also added that she had muscle cramps in the evenings that were relieved by Valium. Further, Em stated that her regular prescribing doctor was away on leave and this is why she presented to Jay.

Em elaborated as Jay requested - I have been taking them for 6 years now and I've cut down. I've cut down in the past 6 months because I know they are addictive. So I'm only on half a tablet a night and only take them a few nights a week. 


Jay became more comfortable but didn't offer to write the script and did not respond to Em's repetitive requests for one. The video recording and interview were terminated by the observers - General Practitioners.

Each party was asked to read their scenario. Jay read Em is a 28 year old female who has never presented to you before and requests a script for Valium due to stress and muscle cramping. 

Em's patient perspective was quite interesting: You present to Jay, a local GP whom you've never seen for a Valium script. You are currently a single mother of two children and work full time. However to deal with anxiety you take up to 8 tablets of Valium a day and see several GP's a week to renew scripts for the medication. Not only that, you know the indications of anxiolytic therapy and the common conditions in which it is prescribed. Your excuses for presenting to a new GP varies from overseas normal prescriber, urgent matters, muscle cramps among others. You lie compulsively and are persistent but not disrespectful. 


When Jay heard that was Em's script and based on how the consultation went, almost broke down in front of the crowd. Her intention was to truly help her patient by appreciating the circumstances behind the presentation and giving the patient the benefit of honesty.

But we all paint a picture of honesty of our patients because if we didn't, the medicine we practice today would completely collapse.

This entry is a reminder to me of how complex the clinical interactions can be and that no assumption leads to safe ground. We are constantly negotiating a minefield that could have catastrophic consequences if coursed poorly. It was heartbreaking to partially understand the gravity that compels patients to go to incredible lengths to lie and provoke us to formulate a false clinical picture. They have the capacity to understand our thought processes and can infiltrate our education, experience, differential diagnosis and clinical management plans.

I just couldn't believe it.

Even now - it's hard enough for us to come to conclusions when patients are legitimate and honest, forthcoming.

This is a whole new clinical scenario - one that must always be lurking around in the fog of a minefield, that is clinical medicine.

Stand-out

Form after form after form.. the Faculty's way of saying welcome to your general practice rotation. We had our orientation day today and I swear we must have received about 50 pages worth of forms to sort out in less than a month and I thought I would have a serious opportunity to catch up on my work for Medicine and Surgery. It looks like, at least for this month, that idea has been blown out of the water.

Most of the presentations were on what general practice is and its importance - like we needed to be reminded. Yes, it is the most difficult specialty to practice and yet one of the easiest to become. If practiced properly and taken seriously by doctors in training, general practice is a worthy challenge.

One presentation was on prescriptions and how to write them out. It was interesting and as can be expected by this Faculty, was our first session on the topic in the course. Even though we've spent two and a half years throwing drugs at people in scenario after scenario, they've finally wondered how the hell we're supposed to do that in real life.

The doctor gave us a particular scenario about a 9 year old boy with otitis externa and otitis media - infections of the outer and middle ear respectively. She asked us which antibiotic we would prescribe this patient and gave us multiple choices to choose from. After that, she generously showed us the therapeutic guidelines' protocol for the treatment of each infection and for the otitis media, the first-line antibiotic was amoxicillin. Yes, otitis media is more important than externa, but that doesn't mean we ignore it - which is what most all students did.

After we had the chance to discuss our decisions with our neighbours (and I explained my decision to my neighbours), the doctor asked who chose amoxicillin? Everyone I could see put their hand up.

She nodded in agreement and then said did anyone chose anything else? So I put my hand up. What did you choose?


I chose cephalexin.


Why did you choose that?


Because according to both protocols, cephalexin is second-line treatment for both but treats both problems and the efficacy compared with amoxicillin in otitis media is not reduced.


Fantastic! That's exactly what we did using exactly the same logic as you and the boy got better! Well done. It's good to know people are thinking outside the box.

That was my moment of today. I was so happy, even though some colleagues mocked me by saying "yeah good work buddy"

In fact, it was such a great feeling to finally hear someone say something so reinforcing, reassuring that about time... things are moving forward. I am developing and in due time, I will develop further.

Positive feedback really goes a very long way. It's a lesson for me to offer it whenever I can.

Smiling in a lecture never felt so good.

The Road to Recovery

Like almost all pre-holiday plans I make while I hurry along to wherever I'm going, I was committing myself to study, research and self-directed learning. Friday of last week, I thought about the catching up I would do with Cardiology and Respiratory medicine.

I have been telling people that I haven't had a weekend or weekday off since Christmas last year. When I say time off, I mean not due to illness or burn out; I simply mean just catching up on the things that make me happy.

Then I remembered the limitations of my commitments to study - I had a few meetings in the holiday break about research and my commitments to the Faculty - so automatically I thought about dropping plans of hours of long study, but I probably wasn't going to do it anyway. The same thing happened with exercise - I was ready to go to the gym every single day on my break.

The meeting on Monday was about my research and it went well - I have things that need to be done but I don't have a good timetable, or an idea about the time-frame I want to complete everything by. After the meeting, I received another 300 papers that require data-entry and analysis, which seemed fine at the time but when I went home with it... I realised the truth: the burden of it was heavier than I anticipated.

It was time for a proper break - no study, no exercise and no commitments except to friends and family. I e-mailed my supervisor the next day and asked her for the week off and she said that sounds like a fantastic idea.

Sleeping late because of accumulated Dexter episodes. Computer games. Books. Internet surfing. Catching up with friends I haven't seen in months.

I wasn't working - I wasn't a medical student. Actually, I lie about the second part; meeting with fellow colleagues meant that you shared a few stories about experiences; gave advice and received it. But that was relaxing - we could discuss cases and understand the consequences; learn from each other and that process never stops. It's better to embrace it than to avoid it.

Either way, it was a great break. I feel replenished with life. I saw daylight, ate delicious food and drank beer. Got stuck in traffic and smiled. Turned the stereo off to admire the moment: the moment I wasn't rushing somewhere.

Yesterday, I took my shoes off for the first time outdoors this autumn and walked barefoot on the grass. It was such an amazing feeling of freedom.

It was a great week and I think this time off will help me get back into my work. I can hopefully reverse the process of quality decline.

General Practice is next and there seems to be much to do. I was thinking of using this rotation to catch up with my Cardiology, Haematology, Musculoskeletal and Respiratory Medicine. With all the assessments, assignments, presentations and examinations they have planned for us, I don't think catching up with Medicine or Surgery will happen any time soon.

The rest of the year will be very delicate - the remaining rotations will all be Specialty Blocks and there will be very little time to study things outside of their realms. This is because Specialty Blocks have their own assessments that must be passed. They are examined in the time allocated to them and that is all you do for them. The Barrier examination at the end of the year tests the Core Blocks, which are Medicine and Surgery - both of which require some serious revision on my part.

Thinking about all of these assessments - I do not feel stressed. I am looking forward to going back and finally getting back into some work.

Writing here is probably the only proper hobby I have. That sounds depressing, but it is the truth and the holiday proved it. My alone time is writing and I love it. I just wish I had more to share at times and time to share it with everyone who reads these posts.

I see the time between my last break and this current break as a big breath hold; this break was my ability to breathe again.

Now, the time comes for another breath hold and I hope I can keep myself consistent throughout it and balance well so that I come out feeling confident, knowledgeable and above all - useful to those people who present to medical practitioners in need of help and assistance. I look forward to meeting them and doing what I can to help them.

The breath hold begins.

Wrapping Up

It has been an interesting couple of months in surgery for me. Most of it, I must admit, has been frustrating because the teaching hasn't been brilliant despite the wonderful tutorials. I'm not concerned about the tutorials - they were awesome. It's more the lack of intra-operative teaching that wears me thin. Knowing the theory behind the surgical processes is important of course, but I am a hands-on learner.

Problems did develop over time. My hospital has been very accommodating and by that I mean the surgical staff were happy to have multiple students per team. This was very frustrating because one kept looking over another's shoulder to observe the operations being done and there was always this fierce competition of who scrubbed in and who didn't. That really sucked.

What really upset me was my own attitude toward my colleagues. I really wanted to be by myself with no other medical students around. Although I got away with it during the first two years of medical school, it now becomes apparent that I just want to be with a team and not have colleagues sticking their noses into my education. I do want other students to learn from teams; it's just that one-to-one teaching in surgery is a very rare privilege and I did experience it from time to time and that teaching was worth more than all the tutorials we've had.

I started becoming rude to colleagues where I didn't need to be. They annoyed me because they kept showing up to our list and thought it would be just fine if they went from one theatre to another until they saw something that interested them... at the patient's expense of course. They didn't help with the patient after the operation, they didn't assist. No no, I just watch you work and absorb. What the hell is that?

Yesterday I was particularly rude with the girl that I was teamed up with because she really did ask stupid questions and I was embarrassed by some of the shit that came out of her mouth. Yes, she's not stupid, but she is really successful at portraying that she is. So I apologised to her in the evening by messaging and told her that should not have behaved rudely. The response I received was thanks for the text. Not sure what that's supposed to mean.

So I've experienced surgery at a very 'tip of the iceberg' level, like most other parts of the course. We're supposed to be part of the family when we're on the surgical teams, but one cannot help feeling like an outsider.

Essentially, most of the registrars were fantastic and some of the residents were brilliant. The exposure to different personalities was interesting and really showed me how people can behave inappropriately to other staff and what unprofessional conduct really means.

One really knows the importance of behaviour in this profession - toward patients and toward colleagues. We must always be accommodating and supportive, regardless of the politics.

Being competitive is always a problem in any workplace. However, destroying other people in the process is definitely not a means to success. Well, at least not for me. Everyone needs to be successful; if we prevent the development of our colleagues, we are literally putting them in the firing line and it's the patients under their care that get shot in the process, well before our colleagues do.

Ultimate Power

People often believe that Surgery is about power. God-complexes and glory. Admittedly, there are surgeons out there with that behaviour. I am the alpha and omega; but the truth is, I'm sure there are many personalities along those lines in other specialties. It's just an inconvenient truth that the personalities Surgery attracts as a career just happens to be compatible with power-hungry people. Delayed gratification has its effects on a lot of medical practitioners and of course, medical students. Being at the bottom of the hierarchy, some thought of being in complete control, picturing oneself in the seat of decision making and constantly being correct, consistent and precise. It's something worth fighting for, especially for people who feel the need to be recognised. Emotional deprivation may not be uncommon among medical students.

However, as much as I want to embark on a journey that will lead me to become a surgeon, one simply needs to discuss surgery and its principles with members of the College of Surgeons to understand the significance of making a surgical decision. Surgeons themselves hesitate to operate - or they should. One should ask oneself: Is it safe to operate? Is it appropriate to offer the person in front of me an operation? What's more, these questions must be highly individualised in order for these doctors to cater to the needs of patients, their values and goals. Tailored practice is best. Leaving the patient with the power to decide what treatment is best is the ultimate goal. Offering and recommending surgery, not deciding for patients, is paramount.

My girlfriend and I were talking about what attracted me so much to Surgery as a career path and the answer was simple: I am impatient and want to see the fruits of my labour. I want my patients to have some element of survival in their treatment goal. Physicians mostly manage disease and retard the progression of the end-point over long periods of time. Surgeons also do the same, however some diseases can be cured surgically and thus prognosis can be fantastic. I do not underestimate the importance of Physicians and that's another reason why I can't become one - they are too smart. I don't think I have the intelligence.

My girlfriend's response was - you're just interested in power; a patient's total submission to you. I paused for a moment. While I think that it is amazing how much people trust surgeons with their vital organs, their lives, it is not the motivator driving me to 'surge' in Surgery.

Essentially, there is only one specialty in all of medicine that has total power. If there is one specialty that patients give their consciousness, life and perception - it's to Anaesthetics.

We must never forget that Surgery without Anaesthetics is not possible. That an Anaesthesiologist is the person who has ultimate control over any person's life while they're 'under'. They are the key to any surgical management - they are they gatekeepers of Intensive Care in the operating theatre. So if one wants ultimate power over individuals, one need not look beyond a Laryngoscope.

The tool of Ultimate Power

Anatomy...

If there's one thing surgeons complain about it's the anatomy or lack there of in the medical schools these days. Yes, at some point in history (i.e. only several years ago) the medical school that 'teaches' me had a significant lack of anatomy in its curriculum. That was quickly sorted out and the volume of anatomy I learned in my first two years was much better than what I heard was standard back in the day. However, there are still issues. Nowadays, although surgeons complain to students about how anatomy is poorly taught in medical school, I must say that it is not entirely accurate - there are student factors.. and plenty of them.

This morning it was time to see a decent operation. We had only one operation booked in and I was determined to scrub into it. There was another medical student on the team and I did ask her if it was alright for me to scrub in and she said yes. What I did and she didn't know was that there was only one case booked in. The way I see it is: if I went through the trouble of finding out what's booked in, asking the Consultant if I can get involved and she merely was standing there - I don't see why I shouldn't be allowed to. Plus, she said go ahead and if she didn't know about the list, that's not my responsibility. It's not hard to work it out.

We had a 59-year-old gentlemen who had a colonoscopy for colorectal cancer screening after a faecal occult blood test came back positive. The registrar in gastroenterology performed the colonoscopy and concluded: There is a large polyp in the proximal aspect of the caecum, which could not be removed via hot snare due to its size. The location of the polyp was tattooed on the proximal and distal segments of the caecum. So it was up to the colorectal team to remove it; though just to be on the safe side, we'd remove some of the large bowel as well.

The surgical procedure planned was a Laparoscopic Right Hemicolectomy, which involved key-hole surgery to dissect the proximal colon and mobilise it up to the hepatic flexure, remove it and anastomose what was left, which would be almost 2/3rds of the colon. Thanks to the public hospital system, we had to wait 40 minutes scrubbed into the case for the technicians to rectify the poor lighting from the laparoscopic camera. There wasn't much success because I'm sure there wasn't money exchange for the fix. On with the surgery!

The operation went smoothly and it was amazing to watch, get involved and hold the laparoscopic camera. I am particularly interested in laparoscopic surgery and believe it is the future of surgery in the abdominal cavity. Minimally invasive, but the potential is nerve racking. Finally, we were able to extend the initial port incision to allow the colon out of the abdomen, so we could remove it. Dissection of the mesentery was smooth and then it was time to staple and seal the segments.

After we removed the large bowel in question, the resident and other medical student were asked to dissect the specimen to find the polyp. The problem soon became obvious - there was no polyp in the caecum or ascending colon, both of which were taken out.

Fuck. Shit. What the fuck is going on? Show me the colonoscopy report!


The anaesthetist showed the colonoscopy report to the three of us - consultant, registrar and I. We all read the same thing - proximal caecum.

Not happy. Surgical exploration is warranted - let's have a look laparoscopically to see we didn't miss anything.


We were back into the abdominal cavity searching for the tattoo the gastroenterology registrar left behind.

Oh my God is that the tattoo there?


The consultant was asking the colorectal registrar and he agreed. It was a bluish stain on the colon. The location: descending colon.

Oh I'm going to teach that girl a lesson in anatomy. We're going to have a nice, long chat. 


Tension grew in the operating theatre. What do we do now?


We must convert this to an open subtotal colectomy. Extend the ventral incision and dissect the transverse mesentery without laparoscopy. Fuck, this is going to be a while.


As we retracted, dissected and anastomosed, the room grew quieter and quieter. Dominating the ambience was the patient's slow heart rate. It is a sound we all subconsciously listen to and it comes to attention when the rhythm is irregular or very fast.

Today, the importance of anatomy emerged. It was always important to me - I loved it. But now it holds a special place in my heart; entire management plans are based on the anatomical involvement of disease.

If there is one thing that has stood the test of time in the context of change in medicine and surgery, it has been anatomy. Of course there is variation in size, shape and sometimes location - but all in all, we must understand anatomy very well, learn to use it and above all, never ever make mistakes describing locations of disease.

Heed my warning. 

Diversion

Taking bloods, inserting a catheter, retracting... the life of the medical student in surgery - the surgical student. Rounds at 0700, I'm struggling to wake up and my bowels don't have any time to work; I just shove breakfast down my throat and wash it down with some coffee. Sometimes I'm leaving the house after triple-checking my keys are in my fist before I slam my front door shut. Half way up the road to the Hospital, I realise I forgot to wear a tie and it's the day when everyone else wears a tie. Or even worse, when there are Professorial rounds.

Yesterday night I drove my car into the garage, closed the garage door and locked it shut with the padlock I brought in from home. This was all before I realised that the shopping I had in the trunk were still in there. Oh yeah. So I unlocked the garage door and got my groceries out, then repeat [as needed]. As I was walking back to the apartment, I realised that one of the other tenants left their cabin light on, meaning that their battery will be dead by morning - a tragedy I've endured before. So I went back upstairs to get some paper and leave my details because I have jumper leads in my trunk. Not sure what happened and didn't hear from them, so it must be alright.

Cooking steak is so simple, yet so satisfying for me. I really enjoyed sitting on the uncomfortable communal couch, folded over the coffee table and tucking into my steak and steamed vegetables. Awesome. In fact, I was having such a nice time, that I decided to treat myself to some port. A few short glasses of that after dinner on top of a delicious steak made me feel happy. I went to my room to study but ended up watching a movie - wonderful.

It was about 2300hrs when I had the music singing at max volume into my head via the big Sony headphones I purchased for 75% off some years ago. Fantastic headphones and great with movies. Suddenly, a massive thud at my door. I jolted out of my chair, feeling slightly tipsy and opened my room door - it was my room mate.

Dude are these your keys?


I went blank, looked around in my room and realised that my keys were missing.

I guess so man. Thanks. Where'd you find them?


His eyes widened and he had that 'ridicule' smirk on his face. They were on the front door.

Oh.. as in my front door in the apartment?


No. They were on the front door of the apartment, not of your room.


Shit.


For about a minute I wondered how I pulled that off and then I realised it was the same way I forgot to wear a tie and left the newly purchased groceries in my trunk after locking the garage door: I'm so pre-occupied.

The obvious question is: what are you thinking about?

My answer is: I don't know.

I get so distracted. My mind's usually everywhere. I find it so difficult to concentrate, sometimes even in everyday conversation. So I reassure myself with the notion that I don't deviate from rock-solid decisions I have made in the past. Until I realise that I have done that before.

What a wonderful way to describe it!

When I was in year 12, I was obsessed with Mathematics - I absolutely loved it. This was mainly because I was very uncomfortable with the amount of alcohol my father used to drink and the amount of arguments that would revolve around his drinking habits. I hated those days and coming home to that every day really upset me at times. Most other times, it was nice and a welcoming place. It still is a welcoming place and I'm happy to declare that things have gotten a lot better. Mathematics provided the distraction from the tension - it relieved it. I could focus on the variables, Greek symbols and get lost in the algebra. It sounds incredibly nerdy, but I'm not afraid to admit it.

So then what kind of a job would a Mathematician have? One could do little with the skill of numerical and variable manipulation without application. I hated Business/Commerce/Economics because I felt that it was essentially the art and science of legally stripping one person, or more, of their money to maximise one's own gains. I still feel this way. So there was no way I was using my techniques exploiting others.

After that came the topic of Engineering. Was I good enough? I wondered how difficult Engineering would be and concluded that it was beyond my abilities. I was even offered a scholarship to do Ceramic Engineering followed by a Masters in Biomedical Engineering. I'm still curious how life would have turned out if I took that path. My skills in Math weren't that great anyway. As much as I enjoyed it, it was a hobby and it would be best to leave it that way. I still enjoy it's logic.

Mathematics is the Language of Nature. 
Every Element in the Universe can be represented by Numbers. 


So now here I am, scraping through day-to-day living in the dawn of my career as a medical practitioner. Medicine started out with me wanting to do Radiology. Why not? You have the greatest exposure to macroscopic anatomy and its spatial relationships in addition to doing Interventional work. After the first year of medical school, I decided that Radiology was definitely not for me.

It was a Surgeon who changed my attitude.

What do you want to do?


Interventional Radiology. 


Really? Well I've got a question for you. I am a Vascular Surgeon. What's the difference between me and an Interventional Radiologist?


Blank.

When I fuck up, I know how to fix it. 


Blank + + +

That shook the idea off my shoulders. Now it's General Surgery... for a variety of reasons.

I look at the first year medical students of today and wonder away:

Wow... I was there two whole years ago. So many things seem natural and yet, we are intimidated by so many other things. 


We've all got a long way to go. In the meantime, I just hope I don't forget my brain along the way.

Are You Ready?

Mrs. Smith is a 44 year old female who presents to her general practitioner complaining of lower back pain. After 30 seconds of listening, 2 minutes of writing scripts and a few seconds of contemplating imaging, the final decisions are:

• Bed Rest for recovery
• CT Lumbar Spine for investigation of ?disc protrusion
• Nurofen for analgesia

But wait.. what do they teach us in medicine? That's right - take a detailed history, perform a physical examination of the relevant region and come to a clinical conclusion... only then should the clinician decide on the relevant investigations. So what's happened here is that the GP took a brief history and skipped the examination completely. We all know it's wrong and I'm sure they do as well. The question is: Why is it practiced? 

The Government, or Medicare, only allow General Practitioners to have a maximum of 15 minutes per consultation and that's pushing it. If one does a Long Case examination, the Faculty of Medicine recognises that this could take an amateur up to 60 minutes ask the relevant questions and perform the appropriate clinical examinations. There is also, of course, the financial motivation - the more patients they see, the more money they make. 

The key to the practice of medicine is the evidence behind the actions decided. Let us examine the facts:

• The literature suggests that bed rest for back pain is contraindicated as it can exacerbate the discomfort
• Radiological findings, even if grossly abnormal, may not necessarily correlate with the clinical presentation - if there is nerve root compression, is there neurological deficit? 
• Perhaps non-selective cycloxygenase inhibitors (NSAIDs) are useful for pain relief, but what about the complications of taking such medications? 
• Side effects
• Peptic ulcer disease
• Renal failure

Results are back!

• Bed rest made no difference to Mrs. Smith - she finds it hard to get up in the morning and do most daily activities such as walking to the kitchen 
• CT suggested centralised L4/5 disc protrusion, however clinical correlation is advised
• Patient is tolerating Nurofen - it seems to be helping thus far

Now what? 

Patient is now referred to a Neurosurgeon for ongoing management of lower back pain.

Great! Neurosurgeons, like almost all consultants in Australia, don't bulk bill - meaning they charge the patient privately and it's their advantage should they have private health insurance. Poor old Mrs. Smith heads over to the Neurosurgeon recommended to her by the GP (i.e. chosen from some random list on the demographic database of specialists). 

Thank for referring Mrs. Smith, a pleasant 44 year old community-living lady who presents with persistent lower back pain. She denies morning stiffness, urinary and faecal incontinence. She does not report any loss of sensation or weakness throughout the day. The pain is constant and is described as pain over the surface of the lumbar region. There is no subjective localisation by Mrs. Smith as to where the pain is. 

On examination, Mrs. Smith seems uncomfortable in the sitting position. She has some wasting over the tibial compartment and has an antalgic gait on assessment. The range of motion of the lumbar spine is preserved with exacerbation of pain in the flexed position. Lower limb examination revealed some level of weakness at the right ankle compared to the left and also some discomfort in the left knee, which seems suggestive of osteoarthritis. 

Mrs. Smith requires ongoing management. We have discussed the benefits and risks of Laminectomy and she is quite keen to proceed. Before any such intervention is formalised, an MRI investigation is warranted. In the mean, I will leave the patient's analgesic management in your hands.

$250 later, Mrs. Smith wonders how she'll pay her electricity bill because her husband is unemployed and her son is still studying. The prices of petrol and tobacco are going up. But how is she going to work after spinal surgery? Oh and that surgeon mentioned paralysis and infection; maybe even ICU admission. What does ICU stand for? 

What the Neurosurgeon didn't tell poor old Mrs. Smith is that he gets paid $5,000 per operation. Not that this would influence his decision to operate on a patient's lumbar spine without MRI confirmation of nerve root compression. It's not at all suspicious that he discusses the benefits and risks of the surgery well before the results are available. 

Truth is - there's plenty of conflict of interest. Mortgages get paid, car payments disappear and top-end restaurant staff are generously tipped. The more one offers treatment, the more money they make and if an honest clinician actually offers patients with an explanation as to why surgery may not be useful, their capitalist colleagues will use the patient's trust to their advantage to recommend surgery. 

So... where are we now? What happened to Mrs. Smith? I don't know - I made the story up based on the experiences I have seen. There are vast differences of care for patients willing to fork out the cash compared to those who don't have it. 

Clinicians are punished for being honest, for caring. 

What kind of a world do we live in? 

Gravity

It's the beginning of May. Time is moving so quickly and it's beginning to make me feel sick. Opportunities swept from under your feet and many approach every morning.

I had a good weekend because I was able to resume exercise after almost a month of inactivity. On top of that, I'm finally studying.

But, I must remember that failure is not low-risk; it can be right around the corner.



On Friday, we had a Pathology session and one of the presentations included some refreshers on Cirrhotic changes of the liver. So I asked myself a question: What is cirrhosis and describe its characteristics. I thought for a minute... minutes... moments... I'm spacing out.


I couldn't describe it to myself. A student who is interested particularly in the gastrointestinal tract could not discuss the principles of a cirrhotic liver and the basis behind its diagnosis as well as its management. This really made my heart sink.

We've been reminded over the past few weeks about a Population Medicine quiz that needs to be done. But! Before one embarks on that, one should read the core articles and perhaps the recommended ones. So I read the core articles and understood the philosophy and theory of Outbreak and its management in the public health setting; interesting and important. But then the quiz... or whoever made it, decided it would be a great idea to ask questions not in the core text (3 articles), but in the recommended text (14 articles). To my surprise, my mark was 45 / 100 -- something I really didn't need to see. I read the core requirements but that wasn't enough for these people. So I'm freaking out... I failed an online quiz. No wait - I failed something. A component of the course, regardless of its academic weight.

I feel like shit.

One thing the assessments in this program are good at is reminding us that no matter how much we break our backs or try our hardest - it's never enough. We always are reminded: we need to know more. Much more.

What kind of a life am I expected to have when I'm expected to know volumes of information, do research, work and do more research? The truth is that this Faculty is not looking after its students.

When I had my meeting with one of the Senior Lecturers in assessment a month ago, it was quite clear she didn't give a shit about life-sustaining employment and extra-curricular research. I remember her reaction quite vividly:

You need to get your priorities in order.


Yes, of course I do. I should study medicine before eating, toileting, showering and shaving. I should study medicine before doing research and preparing myself for College admission. I should study medicine before working to pay for rent, petrol, food and other useless expenditures. Fuck, all this time I've wasted on eating, drinking and urinating. I could've done all three at the same time while studying right?

What's most hilarious is how that Senior Lecturer actually made a point that she did her PhD in Medical Education at Harvard University - how amazing. With all that money invested in what parenchyma she has in that intracranial, intrameningeal space, she couldn't comprehend the complexity behind working for money to sustain income for the facilitation of study and education.

The greater good is beyond reach. I don't want to be gratified; I just want to learn and contribute as much as I can. But no, that's inadequate. Efforts wasted. Time lost.


I was feeling quite good until tonight. Let's just hope it motivates instead of buries me along with all my work.