My GP...

We all need a family doctor. My GP is very important to me. A married man with 4 kids, a wife who had a stroke and parents that live with him; his mother with Chronic Kidney Disease and his father with end-stage Alzheimer's Disease.

He called me yesterday for a small favour and by God, was I happy to hear from him. I really miss talking to him. He really fancies my car and one of his daughter's crashed one of his cars and he needs a new one. So he wanted to borrow my car for a couple of hours to see how it was and to show his family the car he likes.

I told him of course. We arranged a time for the Sunday afternoon and we went from there.

After work, I was on my way home and I called him.

He sounded pre-occupied, as if he was worried or stressed and he probably was.

Could we do what we planned for today another time please?


He obviously didn't want the people to know what we were talking about and I said sure, any weekend you like.

When are your exams?


I didn't know the exact dates - in about three weeks.

Okay well why don't we hold it off until afterwards?


I am still happy to meet with you whenever you're free.

Sure. But only when you're not busy. Okay?


I almost broke down there and then. How is it that nobody except my GP, who is one of the busiest people that I have ever met, can understand me and the demands I have to meet, but my family and girlfriend cannot?

Where is it that life is taking me? What does this even mean? It was a relief to know that he understood but also that it feels rude for me to sound busy to him. He himself is so busy and for me to make time for him takes priority - that's my perspective.

I miss my mentors.

On my Knees

I cried a few days ago and after thinking about it for a few days, I understood why.

In the cold wind of the Brighton Beach, I realised that most of the Surgeons at my hospital were an inspiration to me. One of them in particular, MHK, really can relate to me. He is one of the smartest, most relaxed people I have ever met and he too started out to become a Surgeon. He had it in him the whole time and went through the motions to become now Professor of Surgery.

I understand how hard it must have been. Working so often. He writes about how a Surgeon works hours on end and is still expected to functional socially. He recalls falling asleep in countless theatres and being woken up by a disappointed date. He talks about working 16-18 hours a day and coming home to work on his PhD, the two other Bachelor degrees and a Masters degree he has.

So here I am - a third year medical student in General Practice who hasn't studied anything in 3 weeks; other than seeing patients, I haven't done anything for my upcoming exams in three weeks.

I think about MHK and his study routine. He told me once that he was a Taxi driver as a medical student.

He is from the same part of the world as me - and it is tradition that when someone starts working in a family for the first time, the first payslip should be spent on gifts to the family. We were in the operating theatre one day and he looked at me and said:

Do you know what I bought my parents with my first payslip? I bought my father some socks and underwear, and my mother a jacket. 


Look how lucky I am. I've got a computer, the internet and a car to get me from one side of Sydney to the other several times a week. I can't live up to anything he is.

I can't study, I am an average student and I too want to become a Surgeon in the Public Hospital System. How am I supposed to do that?

Last week, my GP supervisor invited me to a play at the local Anglican College and I fell asleep for a few minutes before the classical music woke me up. I realised what had happened and I could share MHK's pain of social participation. In the intermission, I decided to message him and tell him what had happened.

He wrote back: Hang in there. 


How? There's so much going on. How am I supposed to perform?

I am really struggling to study, to do anything on a routine basis. My exams are so close and I haven't studied. I barely see the people I love and when I do, I am expected to carry out errands.

Did you remember to do this?

What about that?

Can you pick me up?


We should go to that party tonight.


Sometimes I really think life is cruel. I really fucking do. I have done everything in my power to help as many people as I can and I will continue to do so, but the criticism and the expectations are overwhelming.

I think back on MHK and wonder how I am ever going to get there. How am I ever going to survive?

Then as I was reading about the entry requires into the College of Surgeons, I stumbled across the requirements of a Fellow in General Surgery. The number of operations that are expected to be performed independently and alone are tabulated over 11 A4 pages. Where do I start? How do I study?

I am so far behind, is it really worth starting?

All the people that speak highly of me, what will they think when I am unsatisfactory? What will I do when I have to come home and tell people that depend on me that I can't earn money for another year or more? How will I ever pay my bills back? How can I ever be a provider?

28 in 48

The Brass

Inspired by a good friend, I decided to spend two days in the NSW Ambulance Service as part of my Community Placement in the General Practice rotation. I know now that if I had done this in high school - I definitely would've chosen it as a career. It was everything I expected it to be. We are dispatched to help people in dire need when they need it - prioritising only them. Individualised pre-hospital medical care.

The dedication required takes me back to the laziness that has infected medical students: some of us don't show up to rounds, don't assist the interns and residents despite knowing that our help would help them and thus help patients, finish early and of course let's not forget those who do not show up at all unless they have to. The Ambulance Officers work 12 hour shifts and based on my limited experience, do not finish on time - making their shift closer to 15 hours.

As a medical student, it was very important for me to see the role of the Ambulance Service. I loved it and sparked my passion for emergency medicine not for the adrenaline but the principle of dropping everything making that person in dire need the priority.

It reminds me of all those people talking about Alternative Medicine and its importance. Yes, I'm sure there is a role in the care of patients, but when the chips are down and the most crucial physiologies in the body are dysfunctional, we forget our beliefs, how much money we have, whether we're hungry or what assignment is due. We are reminded of cruciality: family, loved ones, our future. Nothing else matters.

I was assigned with the Intensive Care Paramedics - Hardboiled, desensitised men and women who respond not through panic but through logic; something I sincerely lack in my career as a medical student. We had many conversations about protocols, management and interventions. Some of the conversations ran deep...

Have you witnessed any miracles?

They paused for a moment and I could sense that this brought back memories for them.

We have seen people die that should have survived. We have also seen people that should have died but survived.

That's not to impose judgement - they were referring to their gut feeling of survival rather than whether people should have died because they were evil. No dirty hands there.

The comment made by T-man, one of the IC Paramedics moved me greatly: Call it a miracle, call it fate or chance. Call it God. It's all talking about the same thing. The same phenomenon.


That will give me a lot to think about. I'm sure I'll be lost in thought about it when I can focus.

They came up with a nickname for me as well: D-Rok.. and don't ask me how it got to that.

You know D-Rok, sometimes we perform CPR not because the patient has any hope of surviving, but to give the family some closure. When we arrive at the scene, we assess the family and see how they are coping with their relative's decline. If we see that they are hopeful or want everything to be done... despite knowing that they have barely any chance to live, we still carry through with it. At least then the relatives feel some form of closure that everything that could've been done was done and that nothing could have stopped what happened.

Azrael

It took me a while to fully appreciate the gravity of those words. Paramedics are the warriors that fight the physiology of death - delay it by prolonging life until they cavalry is reached.

We, as medical practitioners, often forget the efforts made by others and as a medical student, I will not forget this experience with the Ambulance Service. Those people are incredibly important, crucial, quintessential.

The lives of the population in need are not in the hands of the hospital - they are in the hands of the Paramedics.

I honour them.

Pressure

Not exercising for almost two weeks can really make you feel disgusting, particularly if you enjoy it and crave it. The downside is I know I should go to manage my weight and also because it's a good form of release - but I can't. Something's holding me back and I don't know what it is. The same thing prevents me from studying until it's too late.

Yesterday during my day of sorrow without reason, I decided to do some exercise. I went for a walk by the beach. It was so very cold. With 4 layers, scarf and gloves, the weather really reminded me of how lucky we are to live here in Australia. The winter may be cold, but it's still near melting point compared to other countries such as Russia, America and England. But that didn't stop it from being downright ice-cutting.

It's become almost impossible for me to experience the extremes of emotion without particular music. Every time I write on this blog, drive or study - there's always something playing in the background, usually the same song on repeat for many hours before I need a change in scenery. Yesterday's walk needed my favourite song - a song that I have listened to almost every day for the past 4 years. I still can't get past it - it is so beautiful to me.

While listening to this song, I was thinking about my tutors in the past. Men and Women that have prevailed through medical school, internship and residency - there they are: up in the ranks of the Physicians, Surgeons and Doctors.

Watching them now, being the successful people that they are with families, routine and practice dedicated to helping their communities, I really wonder how I am ever going to get there. Most of them were consultants by the time they were my age because of the wonders of undergraduate medicine.

So I broke down, crying while listening to my song, wondering if I'll ever be half of those people at the pinnacle of my career. I am not even sure I will pass my exams, let alone deliver the care required of me in 18 months' time.

There is only one way to success for me and for most if not all of us in medical school. We cannot deviate from the common path of becoming general doctors when we complete our degrees. Medical school exams definitely scare me and there's plenty of errors to be made and much feedback to be received because truly, I cannot believe that an exam tests my competence. Which is why I'm so confused.

What truly scares me is being out there, as a 'Doctor' and finally managing illness independently and knowing truly that there's plenty of roads to choose from in the light of career choice, number of hours per week, management protocols and many other fields of thought.

All I know is that I am far from ready.

Today

I gave my second lecture to the first year medical students this morning. Given my background in medical imaging, I am suited to the job - a job I created for myself: develop methods of education through interactivity rather than didactic methods to increase the knowledge and experience of first year medical students.

Like most tasks in my life, I put it off until the last possible moment: the night before. I slept well, waking up at 0900 for the first time in some time and got ready to go to my hospital to help a small group of first years fill out some of their assessment forms in clinical examination. They have to fill out two forms to assess their competence in examination. One form has to be signed by a doctor, the other by a senior medical student. And since we were buddied up at my hospital (i.e. the third years and first years developed professional bonds), I made a commitment to help my buddy and his friends. That took up my morning and afternoon including the 2 hours of driving to get me there and back. When I came home, it was time to give the presentation a serious go, which meant finishing it by midnight and rehearsing it least once before 0300.

Mum was happy to see me back home, but I haven't been happy to be home. There is tension in the house between my parents and when I come to visit, I seem to be stuck in the middle of it.. So these past few weeks of visiting at the end of laborious weeks in General Practice has not been pleasant. My dad looks me in the eye and lies about his drinking habits. Why do I care? It's just stuck with me.

Sitting down at my laptop finally and being able to be productive felt good. Productivity is always a form of therapy for me regardless of which context it is in. This is probably because I have been procrastinating so much this year.

The clock struck 1800 and I was confident I could be done in a couple of hours to squeeze in a coffee with my old friend from high school. All of a sudden, I got a call from a very close friend that doesn't keep in touch all that often - DV. She was sorry she hadn't been in touch but really needed my help.

I've had my migraine since Saturday and it's never been this bad. I'm not sure what to do. Can you help?


I told her I would be there in 20 minutes. By the time I got there she was already vomiting and this, to a medical student, didn't look good at all.

Pushing my feelings aside for my friend, I forced myself to be objective and not mention the terms tumour, subarachnoid haemorrhage and meningitis. I simply said it is best to be seen by a doctor in the Emergency Department. To double-check this, I called my GP and explained the history:

I've got a 23-year-old female with right parietal headache for 2 days with some paraesthesiae in the ulnar distribution of the left arm, which has resolved. She feels warm but is oriented to time and place. However she has just vomited clear fluids 10 minutes ago. She has a background of migraines, however states that this time the pain is different and is not relieved by rest or sleep. 


My GP listened to me and also pushed his feelings aside and said: since neither of us know this patient, you should consider sending her to the emergency department.


Sure, I'll take her myself.


A few hours later, we were seen by a Clinical Nurse Specialist and she triaged DV into "to be seen in 4 hours" category. After half an hour, she felt better after the panadeine forte and we left after letting the nurse know. I took her home and shared a cup of tea with her before leaving for home to finish the presentation.

It's almost 2100 and I just finished dinner. My parents are drinking and arguing about trivial bullshit at the dinner table "keeping me company." So after that I finally sit at my desk to tackle this presentation.

I'm finally finished and it's 0130. I'm supposed to be up at 0630.

---- Fast Forward ----

We're in the lecture theatre, almost 300 students and I. They're all fixated on me and I'm there to give them a talk. I break into a cold sweat thinking that I'll look like a total idiot and my presentation will be a stand-up comedy show. I was scared and finally, after delivering the talk for 90 minutes straight, it was over. I received an applause, but I could barely smile. People's feedback was great but I was struggling to be happy.

After another 45 minutes of answering questions by enthusiastic colleagues, I was finally able to get out of the theatre and breathe some fresh air. Mum was with me: I'm so proud of you. I didn't know how to feel. My girlfriend messaged me to tell me that I was great as well - she attended too. Somehow we managed to put our differences aside and keep the relationship alive. Not sure if that was the best outcome, but at the moment, "we're happy."

Mum wanted to take me to lunch and we ate well. Though during the whole time, I refused to let mum share her joy of watching her son's lecture. I can understand that I might be the only third year student to give a lecture to a first year medical cohort, but right then and still now, I just didn't care. On my way home, I called my General Practice supervisor and let him know that I wasn't coming in this afternoon because I would still be on campus for other work... I lied.

So I came home and did absolutely nothing for several hours, feeling the same. Not being able to shake this feeling of presence of absence.

I decided to go for a walk and once again, thought of so many things to write and have forgotten most. I did cry because I felt so helpless.

Today, I think I am back into a depressed state of mind. I cannot call it Depression because I don't think I meet the criteria for diagnosis. I am considering going back on the medications, but do not want to.

I want to call someone to talk about it, but it won't change anything. It won't change how I feel. In fact, I do not think I have the vocabulary to describe what it is I'm feeling, other than unwell.

Blank Moments

It really annoys me... I am away from this screen for most hours of the day and I build up almost half a dozen things to post, write and express in my own words. Now it's 0842 and I have to leave in about 5 minutes. Being late today is not what troubles me.. It's that I have been sitting here for about 20 minutes trying to work out what it is I wanted to share with you.

My memory plays up like this and it drives me crazy.

What's worse is that the thoughts I want to talk about cannot be recorded as they occur to me when I am in with my supervisor. Yes, I should write them down but I hardly get a chance to look at the papers I wrote up during the day.

I am currently doing my General Practice term. There is so much to write about. I will have to think about it carefully and hopefully jot down some of the things I wanted to write about.

I hate being forgetful but unfortunately, it is somewhat part of my personality.

The most embarrassing moment of my day is when I meet someone and within a few moments I have forgotten their name. Awful feeling and it is usually way to embarrassing to ask them again. I just hope that someone else repeats it and I don't forget it again.

It's Time

I haven't written in some weeks now... furthering myself from this hobby of mine because I thought I was happy. Going to the gym, studying relatively well and seeing friends regularly - it seemed like the holiday had done me some good and for a while it was good.

A few things have happened since. Last week, my friend LR and I had to present a case to the specialists and our colleagues on viral infections, which were not taught very well in our degree thus far. All students had to present and we all have been for three weeks now. LR and I presented last week and we were anxious. The presentations so far were quite good and the standards very high. We went in with a smile and presented our 6 night's worth of research, notes and important points. It was all going quite well until the students asked questions we didn't know the answer to and the specialist decided to test the extent of our knowledge by asking us to attempt them. Most of the time we were corrected, but the questions went on for 20 minutes and  it really was demoralising for me because it kept ending in I'm sorry I didn't look that part up or that's a very important question and I didn't look it up. But in the end, we were reassured that it was a good talk. I still have mixed feelings about it.

The most concerning thing now is my girlfriend. She has been through a lot of stress lately - exams, assignments, assessments, job interviews, honours, literature reviews and God knows what else. This has been going on for about 2 months and I have kept my own sorrow, stories and events to myself since. Especially since during my surgical placement she asked me to stop talking about the daily things that affected me - they were overwhelming.. too much. And that's fair. So I stopped talking about myself, my concerns and my feelings. Eventually, I started realising that there was a serious problem with this.

Since I refrained from talking about myself, my girlfriend took advantage of that - she didn't ask me much about my days and enjoyed the attention she received from me about her day, work and study. I helped her as much as I could - picking her up and dropping her off, buying her food and drink, offering to read her work, study with her and be an audience to her presentation rehearsals. But in the process of all this, I was left out. So was my family.

Not going into too much detail, I started feeling quite unwell these past couple of weeks as her attention toward me has been minimal. She doesn't call often or message. When she does, we're talking about her and how she is doing. She also complains that her mobile phone cap is exceeded and I can't comprehend where all that credit is going considering talking to me is free due to our contracts. She tells me she's out studying with her sister, friends or on her own.. but I just can't understand how she's able to do that for 12 hours a day, several days at a time. If I look at one factor at a time, it seems reasonable - but when I put it all together into how my girlfriend is behaving toward me - it doesn't seem right.

I started losing sleep. I lost my appetite and couldn't study. I didn't feel motivated to get in touch with my friends or to pay my bills on time. I started getting scared about all the work I have to do with research, the end of year exams and my professional commitments.

The last few days - my whole life seemed to have changed. I was doing absolutely no study and work was only something I was doing as a necessity, not as a vocation to help others. I started distancing myself from my family and my friends - I didn't want to take phone calls, or make them. My eating habits have gone haywire and I have been eating more unhealthily in the last few days than I have this whole year.

She asked me to call her this morning because I told her I wasn't well. After talking about my loss of appetite for a while, she realised that maybe there was more to this than my appetite and asked: do you want to start an argument or something? - it sounded like she was expecting me to be angry with her.. so it's almost as if she knew she was doing a few things wrong. So I told her I wasn't angry; I was feeling neglected.

Neglected? What the fuck do you think I've been doing all this time? You're so selfish!


... ?

Talking to my 'soul mate' about the fact that I feel alone and left out made her think I was selfish. And normally, I would feel very guilty about that given her situation of exams and work. But I couldn't believe she lashed out at me when I told her what I did. It infuriated me.

Stop playing games with me. If you have an issue with me or anything, why don't you spit it out instead of keeping bottled up all this time?


The answer to that was simple: because you've got a lot on, I just don't want to be in the middle of all of it and I've ended up there anyway. 


So what do you want?


Well, with that attitude, I was NOT in any mood to tolerate anything.

Well I called you because you asked me to and to tell you that I am not well, feeling sad and down. I bring up that you are the reason that this is happening and you call me selfish. I don't think you care about me - I think we should break up. 


When she's pissed off, she says anything and that makes me very angry because her words do more than sting, especially when I'm feeling as vulnerable as I am now.

Let's break up then! I'm sick of your bullshit. 


That's what I get told when I call my soul mate to tell her that I'm feeling down, upset and hurt. So I simply agreed and hung up the phone.

I thought we had something going. But as time has gone on - it seems that this was mostly about her. My studies, my life and my worries are but 4th or 5th on her list of concerns.

I never envisioned it would come to this. I was hoping we would get married, have children and take care of each other. We have spent the last 4 years developing what I thought was something beautiful.

But now, the foundations of the 4 years have been shaken, probably beyond repair.

I will not contact her. But somewhere inside me, I hope she attempts to sort it out... but in the same place, I know she won't.

Coping Mechanisms

One of the most traumatising experiences in my life was visiting the Morgue. From the moment I heard we had to do this, I wanted out. Not interested. Yes, I acknowledge that I need to know what it is and the processes involved, but can I not read it in a book? No.


It was surreal - two rows of about 10 trolleys suspending the 'shells' of life. Some of the bodies were surprising as they looked very healthy and fit; some were also young. Then there were the others - massive impact trauma, negligence and more. Watching the technicians work on the remains was horror in its own right... saws, blades and retractors - unlike surgical equipment with smooth borders and sterile. This was the real deal - autopsy.


I wondered how these people, Pathology Registrars and Mortuary Technicians actually went home at night or had a few drinks with friends. How do you participate in 'normal' activities day after day of butchering?


The concept of 'Coping Mechanisms' was brought to my attention by the tutor. I watched with disgust as the Technicians laughed at jokes, discussed sport on the weekend and socialising. They weren't joking or laughing about the deceased, but it sure felt like it. I was horrified with what they were doing, how they were doing it and how they distracted themselves. On top of that, all my sensory inputs were shutting down and that vomiting reflex was creeping up on me. 20 minutes after we entered the rooms, I left in a rush. I slept the rest of the day.

Although it was inappropriate for these Technicians and Registrars to laugh and socialise while doing what they were, I realised that this was only my perspective. I am now confident, thanks to a colleague, that they would've felt the same when they first started. Eventually, we all come to realise that someone needs to do it and may they be blessed for doing what I cannot do. I could never do any of that and these people are eternally stronger than me for being able to suppress everything and get on with it.

Coping Mechanisms are substantially variable. Unlike the examples above, it's obvious that in the clinical setting, people's reactions to disease, pain and suffering will be different. And as healthcare professionals and medical practitioners, how do we cope with these day to day encounters?

In The House of God, I read about people distracting themselves through isolation. In one book, the Intern could not take what he saw every day and had trouble coping with the patients' question. He became obsessed with exercise, neglecting his family, friends and 'external life' for exercise and then hospital time. It wasn't until his friends realised what happened and they dragged him back to who he was before, just with a higher pain threshold.

In another book, the author describes his method of Coping through continually working. This provides a distraction and being constantly busy means one can only focus on what they're currently doing, not on what they have been doing for the past... 70 hours straight. He's obviously a Surgeon and he makes a perfectly good point about decompensation - you work and work, cope with it all and then, sleep prematurely absolutely everywhere and watch the friendships and relationships shatter around you as you wake up to a new day in the theatre... oh wait, it's still the same day.. Shit I'm on call again.


Talking to colleagues about Coping Mechanisms I've heard a variety of them:

• Exercise / Gym / Outdoors / Training
• Travel (domestic and international)
• Reading Books
• Photography
• Music
• Sex
• Spending time with family
• Binge-eating / Binge-drinking
• Medications (SSRIs, Benzodiazepines)
• Self-medicating (alcohol, opiates, marijuana, ecstacy, etc)
• Yoga / Meditation
• Religion

Those are the common ones I have heard. I think it is obvious that we all need a few of them and besides from exercise, I think this Blog is definitely one of the other mechanisms for me. I do self-medicate with alcohol at times, but that hasn't happened for a few months. 

Then I came across one exception. My tutor in first year - Dr. MG. I was offering the first year co-ordinator to take on some tutorials or perhaps organise some sessions with students and she mentioned that Dr. MG was taking several weeks leave as his 2-year-old son was admitted to Intensive Care. We didn't know why. I became quite concerned for Dr. MG because of his character. He is a very closed person and one can never know what he is thinking or feeling, except when he is laughing. I can't tell if he's stressed, or he's had enough. A man made of bricks, full of knowledge and endless experience, but no outlet... at least not to me. 

So one day during the Surgical rotation, he came up to help with an Endoscopic assessment of a patient and we left the theatre at the same time afterwards. I decided to ask him what happened. 

Well, he is a 2 year old boy whom had neurological deficit based on my impression and was admitted to the Emergency Department when he started vomiting. He was diagnosed with a cerebral arteriovenous malformation. He is recovering well after radiotherapy to the region of interest and will be discharged home on a few medications. I'll monitor him closely and eventually he'll require neurosurgery for correction. Thanks for asking.

I wished his son well. We parted ways - he was off to the endoscopy unit to correct some gastrointestinal bleeding and I was on my way home. How he responded to my question of concern was alarming. He presented it like his own patient, objectively and put me in the perspective of his colleague. Thinking about it for a while, I concluded that the way he communicated his son's medical situation was frankly disturbing... and I have no idea how he copes with it.

Some people are so strong. They can stand tall with their back straight and regardless of what happens, their posture never slumps. I cannot fathom how they can possibly prevail everyday in a sound mental state with no sense of release. Thinking about it now, I wonder how his son is doing and why I care is not only because I care about his son, but I care about him. He's a good person, a good man. And I just feel that he keeps everything to himself and as inappropriate as it sounds, I just want to be there for one of my role models... one of the Consultants I admire and respect. Just once.