We Must Continue

Next week is my last as a medical student in the hospital. When I return in January, I will do so as an intern. How time flies right by. It will be an opportunity to make new friends and work alongside colleagues. Once again, we will all be going from the most senior people in the chain to the weakest link in the chain. Although we keep getting assured by senior staff that interns are the backbone of any medical or surgical team, I can't help but feel the role will not be as fulfilling as one would expect after finishing years of study. I also feel that although the role may not be "the weakest link" (if there is such a thing), I may not perform adequately to meet expectations. 

Why am I not excited? Why don't I feel all nostalgic while some of my friends have been counting increments of how much of a fraction of a doctor we all have been up until this point? Why can I not smile about it?

I look beyond internship and notice the people around. I've said how much in love I've been with general surgery, but now I have my doubts. Does that cripple me? No. It's reassuring and somewhat refreshing to know I don't have to pressure myself to do what it is I've loved in the past based on but a few months of time in the operating theatres. But then again, I haven't stepped foot as an assistant in an operating theatre for quite some time now. 

Maybe it's delayed gratification. The people around me seem to be doing so well. I've got dreams like everyone else; but unlike some people, they seem to remain as dreams. 

I bought myself a car less than two weeks ago: my gift to myself for all the years of 2-3 jobs and university studies. I was so excited and so happy but now, I feel like I don't deserve it. What have I done? Should I have saved the money for a house or a share portfolio? Perhaps a holiday? It's the largest loan I've taken out for myself and it'll take me at least 3-4 years to pay it off. It also puts even more pressure on me doing extra hours next year.

Somehow I've set myself up to work like a dog, more so than I've ever done. My weekend job's boss contacted me to work 7 days a week before the Christmas break, which I agreed to and they have also asked me to stay on as a relief on-call person should the need arise for support on the weekends, so long as it does not conflict with my responsibilities as an intern next year. So the potential of two jobs will still be on the debating table. Not to mention the lecturing will continue and I have no idea how medical administration will react to all these "extra-commitments". At the same time, will I be able to cope? 

Then there's that problem about whether the masters of surgery coursework is a good idea. I want to do it so I have something under my belt other than a medical degree, which these days is inadequate on its own in a worthy application for specialist training. 

There's so much stress and I'm not sure what I should be feeling. My girlfriend and I have organised an overseas trip for 12 days during the new year period and I'll be back a week before I start work. I'm stressed about whether I'll have my life organised in a week. I'm worried about the trip; whether it will go smoothly or not. I'm afraid of flying. 

Maybe I'm just having a bad run. I feel sick and I can't sleep. I just need to breathe and focus on one problem at a time. 

One at a time. 

"You should make an appointment"

Medical students tend to have overwhelming schedules... so we think, until we meet the medical registrar on the evening shift. Finding the right balance is the most difficult part of my daily life, where like most people I want to fit in activities for study, work and leisure. Having the nagging thought of reminders constantly indicates that I don't seem to get the balance right and I seldom go to bed in the evening without the feeling of satisfaction.

Two weeks ago my colleague and I bumped into each other and he suggested we have coffee "some time." Both of us frantically looked at our schedules to see if we could squeeze in a quick espresso, but we quickly realised how unlikely it was to actually sit down and enjoy each other's company for 30 minutes. In the end, we ended up committing to a time, then postponing, then cancelling and the whole attempt ended up being a complete failure. We had a good laugh about it!

What keeps clinical medical students so busy? Putting personal and social commitments aside (unless you're a cohort's social representative), the clinical hours (rounds, clinics, theatres, wards), tutorial preparation, self-directed learning and extra-curricular research... all of which is quite different than examination preparation and thus requires a different approach to study (depending on the exam). Add on top that you are relatively poor (compared to other graduates our age), doubtful of your career path and constantly telling people who comfort you that you can't see them - you've got a pretty decent mixture of stress, low emotional state and a lack of motivation. This is obviously not a picture of all medical students.

Clinical responsibilities of medical staff are not confined to the walls of their respective wards. They extend into the emergency department, colleagues requiring expert consultation, outpatient clinics and meetings with other healthcare professionals.

But how are our lives any different from any other person in the world? We all have families, friends and responsibilities. We are looking after the sick, who are in fact being denied to carry out and complete their daily tasks, whatever they may be. Imagine being in a state where you are unable to be productive at your normal pace, where your inertia gets completely knocked off its chair.

It's a quiet Sunday at work. I received a phone call in the morning from a 48-year-old lady telling me she needed a CT scan of her abdomen because of "abnormal ultrasound results". She lives a fair way from here, but she was up here last month for work and was directed to the medical centre by a nurse, who thought she was quite unwell.

She wanted to arrange a CT scan in this area, but I arranged for her to have the scan closer to home by faxing the referral over to another department and setting up an appointment. The receptionist at the medical centre who was keeping the referral happily handed it over, saying "she looked very unwell."

Medical receptionists aren't trained medical staff and therefore could not reliably pick up subtle clinical signs, but when they say "this person is really sick," - it's a suggestion that the abnormalities are so obvious, that they're screaming at the trained clinician.

I dug up the ultrasound report:

History of jaundice, acute upper abdominal pain and ascites noted. 


There is diffuse fatty liver infiltration with no focal masses. There is no intra- or extra-hepatic biliary duct dilatation. There are multiple prominent veins in the epigastric region. The gall bladder was not seen. 


Further evaluation with a CT scan of the abdomen and pelvis is suggested to identify the cause of the patient's prominent epigastric veins.


When I called the patient back to emphasise the importance of getting the scan and following up with her doctor, she replied "I know I'm unwell and I can feel it in my heart that things aren't good. But I'm working almost 15 hours a day and I've got to look after my children. It can't be good that I've got bruises everywhere and that I occasionally bleed from my nose and ears."

I almost fell off my chair. This poor lady with fixed professional commitments was working ridiculous hours, almost every day of the week and also looking after her children. I presume she is a single mother as there was no suggestion she had a partner. She had convincing features of liver failure.

It feels very satisfying for a medical student to recognise patterns of illness and to confidently make a diagnosis. This was one situation where I was devastated to recognise what was going on.

We all carry on with life, all our commitments and may never consider how brilliant our functional capacity is. It's also quite interesting to know we usually feel no signs of good health compared to poor health, where it is reflected through symptoms and signs. We are working machines everyday, like clockwork. We work for our future and the future of our children; for financial commitment, to live comfortably and sometimes, to provide for those who were not so fortunate.

So I'm sitting in silence, wondering whether she'll make it to her appointment tomorrow.

The most I could do was as much as the GP could do: tell her this is one of the things you definitely want to follow up... and fast.

ChAos

Medical School always emphasised the correct order of clinical assessment. I'm sure many colleagues would remember a few times during our endeavours of being prompted to assess in the proper order.

One must always begin with the presenting complaint, then take a history of the presenting complaint. Soon after the presenting complaint, one must pay attention to the patient's past medical history, medications and allergies. One should always ask for the patient's family history to determine if there are underlying genetic diseases. Never forget to ask about smoking and alcohol consumption. Also, have an appreciation of the patient's baseline function, their finances and also what they do for a living to understand the impact their illness may have on their lives. The physical examination of relevant organ systems is then performed guided by the history. Based on the findings and provisional hypotheses, one would order investigations that will allow for appropriate management and definitive, evidence-based care. 


In the Emergency Department however, things are quite different. Patients are not often in a position to answer dozens of questions related to their illness. Therefore, the order of the Physician's assessment is distorted. The "shoot first, ask questions later" approach is the mainstay of Emergency Department care, where clinicians are often providing management for patients and occasionally squeezing in a question or two in the process.

On our first day in ED, the six of us sat down with the staff specialist and he asked us a question: A 68-year-old lady comes with chest pain. What are you going to do?


Medical students above all else are taught to be safe clinicians. "If you don't know what the fuck is going on, start with the basics. That might stall you long enough to get to the right answer, or in fact, you may have actually answered the question." We answered the staff specialist's question in the traditional Physician's model.

"We should assess her general appearance."
"I would like to know more about the chest pain."
"Has this ever happened before or is this the first time she's had this pain?"
"I think we should examine her cardiovascular system."

The staff specialist listened patiently until all our eyes were fixed on him for the correct answer, even though one could argue that all of our responses were correct.

The first and foremost step in the assessment of any patient with chest pain is an ECG.

In this patient's presentation, which is a common one, the first and foremost knee-jerk response is an investigation rather than a history or physical examination. If one peers into the literature behind this, it's definitely the most appropriate thing to do. It's just so different not practicing the Physician's methodology of taking a history and performing an examination.

The sole purpose of any Emergency Department is to ensure patients are not critically ill, and if they are: resuscitate them. If they are not, either discharge them with GP follow-up or request intervention from the relevant specialist teams. 


Mr. CE is an 82-year-old man who presented to the ED with the complaint: "my heart is missing a beat." At that point, I was attached to the hip of Jackie, an experienced ED resident, and we were seeing patients together. She pulled out his ECG and gave it to me. What do you think?

As I tried to make sense of Mr. CE's myocardial electrical activity, I didn't think his presenting complaint was very critical (in terms of life-threatening causes).

"It looks normal, but I would definitely get a pair of experienced eyes to make sure."

Ok. Well, here's his ECG from 2010 when he presented with a similar concern.


I had a look at the previous ECG and it didn't seem all that different.

Yes, he's had multiple presentations to our department with similar complaints. Although it's less likely to be critical, we should still see him to ensure everything's all right.


The nurse brought the patient into one of the Acute Care observation rooms for patients who are relatively well (i.e. alert and oriented as opposed to moribund).

Immediately, Mr. CE's eyes lit up when we walked into the room and introduced ourselves. He was telling us about why he came in, but often deviated to talk about his past days as an automotive engineer and spoke about his ex-wife's bipolar disorder. The missing beats usually occurred in the morning during breakfast, when he also noticed his temperature rise but not enough to cause a fever. He denied chest pain and any other significant cardiac symptoms. So in the eyes of Jackie, Mr. CE was good to go. The only problem was actually getting out of the conversation, as Mr. CE was so keen to talk to us about whatever he could. At one point I thought he might have been delirious, perhaps even have some flight of ideas (i.e. jumping from one topic to another with no rational transition).

Given that Jackie is a resident, she had to check with the staff specialist, who thought everything was fine but wanted to see Mr. CE herself. So I tagged along and we listened patiently to Mr. CE propel the conversation and the staff specialist was doing whatever she could not to offend him, as she had other patients who required more immediate attention. I think that is one of the rarest qualities of a good doctor: seeming as though they have all the time in the world to listen to a patient's story.

Mr. E, we're confident that this issue is not life-threatening and would be better looked after by your GP. However, I would like to have a look at your urine to ensure there is no underlying infection.


She was worried about an underlying urinary tract infection, which could be making Mr. CE delirious.

Jackie was writing up some notes. She looked up to see whether the staff specialist's impression had changed from her case presentation.

I think the diagnosis is loneliness. 


There it was. It made perfect sense. The poor man had multiple presentations to ED throughout the last couple of years and looking through the previous admission notes, it was clear that he was as talkative as he was on the day we saw him. He wanted affection, attention and respect; the basic things everybody should have in their lives on a daily basis.

In my mind, that's how pathetic our society has become. Neighbours don't look out for one another let alone know each other's names. There's a very high incidence of divorce and separation, suggesting that even the deepest connections between people may be flawed and or we lack the language, effort or love to talk them through. Let's not forget about the horrendous stories of people being found dead in their apartments not because they were visited frequently, but from the odour their remains had left to the other tenants going about their business. Even then, it's about "make the smell go away" rather than the "there's something seriously wrong."

All three of us just stood there in silence, remembering that an important but tragic differential to any non life-threatening presentation may just in fact be a lack of human physical contact, just to start all over again with another person willing to listen.

The saddest part about all this was we couldn't give him the attention he craves. In the principles and practices of emergency medicine, Mr. CE is ready for discharge, never mind his solitude.

In the ED, things are done out of order such that the most common life-threatening diseases are identified as soon as humanly possible.

Unfortunately, it's a unique environment where the patient's needs may not necessarily be addressed and the care maybe misinterpreted as distant, objective medical practice... and the catch is: it's not a misinterpretation.

It's exactly that.

Token of Inspiration

Medical students have often decided their career paths before graduation and some proportion of colleagues had decided well before they started their studies. Some of us are hell-bent on certain specialties, even sub-specialties. Others are trying to find their feet through the chaos of it all. We are all at different stages of the decision-making process and the path before us has as much twists and turns, if not more than the path that lies behind us all.

Sometimes I ask myself what factors allow students to make firm decisions about their future. Perhaps it's the exposure and our experience through the rotations. Maybe it's our academic thirst to understand the underlying principles of diseases affecting certain organs. Could it be for the detrimental effects of specific disease(s) on the population? Or it may even be our passion to help people in the areas we are most comfortable with. Of course, let's not forget about those who want to study diseases that have or are affecting them or their loved ones.

Thinking about it reminds me of the times I started to seriously consider the rough climates and violent seas of the surgical pathway. When did it start? Where did it start? Most importantly, what was the context in which it started?

It definitely started in the operating theatre, which is no surprise I'm sure. I was in my first year and we had just started studying the musculoskeletal system. Our hospital didn't have many rheumatologists at the time, thus the clinical teachings were conducted by the orthopaedic boys and girls (yes, there were girls).

Dr. QD was the orthopaedic surgeon who made us feel he had all the time in the world for our questions. He asked us all to take turns bringing shorts or singlets so the group could examine one student at a time, rather than asking surgical patients to volunteer for strenuous tests on joints. The week we examined the foot and ankle was my turn to be the patient. I sat down in front of the group of 10 students while he explained the importance of watching someone get undressed to understand their global function, restrictions and disabilities. I proceeded to take my shoes and socks off as everyone watched quietly. At that point, we were all just trying to understand what normal was and I definitely was not a good example of that. I hadn't told anyone I had a problem.

The interesting part of examining your colleagues is one can always pick up underlying abnormalities that have gone undetected for many years. The majority of these are "innocent" heart murmurs. But I had something else going on. So I knew full well Dr. QD was studying me as he was studying all of us every week to ensure the findings were in fact normal. I looked up at the group after I rolled my trousers up to my knees and asked "what do you think Dr. D?"

"You've got a lot going on there." My colleagues were confused as they didn't notice much wrong through their untrained, inexperienced eyes. It was also the fact I had mechanisms in place to make the abnormalities as subtle as possible, just like anyone else with health problems.

After my colleagues took turns examining me and asking questions, Dr. QD and I spoke briefly about my "orthopaedic problem". That's when we built some rapport. It's also when he agreed to let me into his operating theatre every Monday morning.

It was my second Monday morning in theatres and I was thrilled to watch the amazing things they do... from the anaesthetics bay. I remember walking in and feeling the stress of the staff: nurses running around getting equipment ready, the anaesthetist sedating the patient and Dr. QD quietly looking at an MRI of the knee. He was alone and studying the images carefully. "Good morning!" - he turned around and the look on his face was almost "thank God you're here."

The registrar's wife was in the middle of giving birth and Dr. QD told him to be by her side. He had no assistant until the other team's registrar was free to assist him... after their morning list, which wasn't helpful. "Could you give me a hand?" he asked me. "Of course," I said but I didn't know how to scrub or what to do. "Follow me, let's get started before the patient is ready."

He patiently taught me his technique and I carefully imitated his motions. We scrubbed together and my anxiety settled with his patience. He showed me the way to wear gloves after putting gowning up. After several failed attempts of putting on gloves with the gown's sleeves, we both realised time was running out. He asked the nurse to open a new pair, which he took and stretched for me. "Here, just slide your hands through" he said. It's the only time in my life a consultant ever held gloves out for me. Not that I'm special, it's just unheard of.

Luckily about half way through a total knee replacement, a junior registrar showed up and took over my position as first assistant. We completed the procedure altogether and it was a team effort. At the end of it, Dr. QD thanked me and I left to attend the late morning's tutorials. It was then I was sure I wanted to do orthopaedic surgery.

Was I? Ever since the end of our musculoskeletal studies, I lost interest in it while my curiosity for general surgery grew. Something changed... but what was it? Eventually, I forgot about orthopaedics until recently.

Paediatrics has been a tough rotation not only because it's difficult but because the dedicated children's hospital I've been allocated is infected with political bullshit. People are anti-social, arrogant and occasionally just rude. After following them around for several hours, they throw you a bone with a short piece of knowledge that you read the day before.

It's my fault - I expected to get a lot more out of it. My first week was orthopaedics and given I had spent my elective mostly in theatre, I thought it would be a good idea to have an understanding of what outpatient medicine was like in the fracture clinic.

The orthopaedic team were welcoming, friendly and we clicked quickly. Next thing I knew, I was assisting in theatre when needed and when they didn't, I was seeing patients in the clinic. At first, it was with the fellow. A few patients later I was seeing patients on my own. I would take the history, present it to the consultant or fellow, show them the follow-up imaging and offer my management plan. They would obviously over-write it with a more precise management plan while giving me constructive feedback. It was an amazing learning experience.

There was an icing on the cake as well. It was Thursday and the rostered consultant showed up to the clinic: it was Dr. QD! We were both very surprised to see each other again. We shook hands and caught up briefly. "Good to see you again mate." I explained I was here for a week during my paediatric term. "Well, we have a busy clinic this morning! So, let's get to it!"

So off I was seeing patients on my own and by the end of a six hour clinic, I had seen 40 patients. The experience was amazing. I decided to stay back and see some patients in emergency with the orthopaedic registrar. Dr. QD was the on call consultant that evening and I had a brief chat to him on the phone.

"You should really consider orthopaedics mate. It's a good career choice and you've made it clear you can tolerate the workload. Thanks for your help today." I was very happy he gave me his opinion and it very much lifted my spirits. There's nothing better to be useful to both patients and doctors as a medical student.

After almost four years of being a medical student and pondering about the influential factors facilitating our career-decisions, I realise now the most important factor is our personal experiences with the teams we are allocated. It's the passion of the team, their dynamics and we hope one day, we return to the very same team and do more than we ever thought we could. At least that's what I want, but teams in hospital change every six months if not more frequently. We all move cities, hospitals and get rostered on different times.

I'll never forget the people who didn't brush you aside as a medical student. They took me in, realised my potential and convinced me that it's possible to do what I'm expected to do in a few short years. Unfortunately it's uncommon; doctors don't teach very much because they are over-worked and pre-occupied with more pressing issues.

Overall, the people that validate you with recognition and the allocation of responsibility are those who we wish to see again and work with in the future. They are the essence of my inspiration.

Who knows? I am actually re-considering orthopaedics as a career choice and the only substance behind that are the brief, direct words of Dr. QD, orthopaedic surgeon.

The Symbol of Orthopaedic Surgery

Chilling One Day; Some Day

I'm in the middle of a bar waiting for my other colleagues to show up so we can get on with our revision of Medicine, Surgery & Paediatrics. After a schooner of light beer, I'm already feeling light-headed and after 2 meals and 2 snacks, I'm feeling hungry again.

The day was filled with lectures, slides and learning objectives. It's much like any other lecture day for medical students. What I find so profound is there are pages and pages, chapters if you like, dedicated to describing single dot points lecturers have summarised onto a single slide of a 67-slide presentation compressed into an hour. This means that one can spend days if not hours going through a single lecture, when in fact there are so many to go through. Plus, there's the self-directed learning, integrated clinical attachments and assignments that are all to be done prior to our examinations.

There's so much to cover already and the work is definitely piling up. I decided to write this entry because I read Sharp Incisions' last entry on the blog. She was a point of hope for me; she solidified my faith that there were medical students out there who will push forward and beyond what's expected of us.

But she threw in the towel for her blog and I'm incredibly happy she has decided to devote time to what means most to her.

Why can't I do that? Why do I stress about things like organising all these extracurricular activities? Stressing about things like attending social events, whether I'll be able to control my diet for the day and how many cups of coffee I've had? Because I do -- even if I am just sitting comfortably somewhere trying to relax, I'll stop what I'm doing to focus on what's stressing me out.

It's all getting overwhelming again. Interestingly, my schedule in the elective term, which demanded more hours, was easier for me to handle. I happily went and did what I was capable of doing competently for 10-18 hours a day... after which I came home satisfied with the difference I made.

I'm back here in Sydney, back in my own role and financial circumstances. In other words, I've come back to real life and it's been an eye-opener how much more difficult life is over here, even if the hours are shorter per week. I'm slowly understanding that the number of hours one works or studies a week doesn't determine how awesome they are; which was obviously quite a weak assumption for me to make previously.

However here I am, trying to figure out how to critically appraise a guideline on Paediatric Anxiety & Depression for tomorrow's presentation while waiting for my colleagues to arrive so I can summarise surgical diseases of the Breast and listen to their summaries. I've hit a brick wall and can't get in touch with colleagues that know how to access the appraisal tool we're expected to use.

Sharp Incisions, I hope you find your feet and please, for the sake of everyone out there, never take off those spectacles. Medicine is not just another job - you reduce morbidity, mortality and make a difference to people. You can give them hope, care and comfort without their financial commitments. Just like all of us, you need some time to yourself, your family and to smile again. I'll miss your entries and your insight.

Like everyone else, I'm in a bit of a rut right now and hopefully when I wake up tomorrow, I'll feel better and won't constantly remind myself of the upcoming exams, assignments, professional and personal commitments. One day, I'll be able to wake up and focus on absolutely nothing but my plate of breakfast in front of me. Until that day, I'm going to push forward - I need to believe that day is going to happen.

I really do.

Input Peripheries

It's been a few weeks since I returned from my Elective term and it feels different being back in Australia. My time overseas was not awful, and the living conditions were far from terrible. However, there are certain comforts one takes for granted and yearns for while overseas; perhaps that's what people mean by the expression "home-sick".

The first week of Paediatrics was packed with lectures and presentations. Chapters and endless pages of literature topic by topic all squeezed into one or two hours at a time. I think it's rather humorous that Clinicians emphasise oh so very much the importance of evidence-based practice and yet, we are still using traditional didactic teaching methods with some additional fancy gadgets compared to a few decades ago... all of which arguably have little evidence in the context of educational efficacy. But hey, that's why we have clinical attachments for the next three weeks - where each week we'll all be in different departments. Just when we get the hang of where to show up at what time, the names of all the staff members and our second chat with the consultant that involved being asked questions we couldn't answer, we will be off to experience the disorientation again in another department. Charming!

But I don't really mind. I just enjoy predicting how miserable I'll be in six weeks from now. So on our first day back, I was curious about how people might have changed after their elective term. How did their experiences affect them? Are they affected at all? I pondered all the way to the wrong train station, then all the way back to another train station and then back on the wrong train again. I showed up at 1045 when we started at 0830. I don't think I've ever been so late in my university years; at least not by mistake.

Morning tea time! Unheard of in my elective hospital and something I welcomed before our next couple of lectures on a Tuesday morning. I was talking to one of my colleagues, who is hell-bent on becoming a surgeon and already in the process of deciding which pathway he should take to become the sub-specialist he would like to become. I admire people who have already understood and appreciated their years ahead, but being so specific? I can't help but feel their insight must be restricted to what they've seen in the context they saw it.

I listened intently to his stories from New York, where he saw dozens of trauma cases, scrubbed into case after case learning techniques and getting down to the fundamental principle of Surgery: to save life in dire need. He was sure he wanted to become a Trauma Surgeon and from his list of credentials plus the scholarship he received to see what he did, I see him on the successful path to doing exactly what he wants to.

He passionately explained "procedures unknown to us in Australia" to save the lives of people who were in horrific accidents, victims of domestic violence and gang warfare. He described the unique procedures to me and yes I agree, they were quite radical and probably not performed in Australia routinely. And only a handful of people could perform them.

But throughout this encounter, he never explained anything about the patients except for their presentation to hospital. Typical surgeon I hear you say, but that's not true. Surgeons must still take an interest in their patients beyond their anatomical planes and site of haemorrhage. Patients are not just a list of potential complications, risk factors and mechanical defects... and to hear my colleague explain these patients and their management depressed me because I'm sure he didn't know a single one of their names.

So some of us are already falling into the trap of adapting personality and behavioural traits that will not make us good doctors. And this fine medical student, a distant colleague of mine, is well on the way of becoming what he always dreamed of... but I'm sure somewhere in those dreams he didn't consider the guilt of not providing reassurance, or empathy.

Perhaps the whole point of being a Trauma Surgeon is not to interact with people or obtain consent; the law has provided that for you - just ensure the patient is resuscitated so that they can form opinions again. Oh and if their opinions were not what was expected (i.e. instead of "thank you so much, God bless you, I'm alive" one is told "you couldn't spare two minutes to explain what you did; you told me to come back in two weeks to be seen again but I don't know why") - then maybe, just maybe, the principles and philosophies you (medical student) based your career on need revision.

The problem "is" choice.

Welcome to the Operating Theatre

Stepping inside an operating theatre can be daunting for anybody. It is a unique, somewhat uncomfortable environment where people have an unusual sense of humour and a rare degree of multi-tasking competence. The sterile field, everyone dressed in the same scrubs with masks covering their faces makes telling staff apart impossible.

What is the role of the medical student in the operating theatre? The answer varies from useless to critical. If you're in a fully staffed operating theatre (i.e. one surgeon, one registrar, one resident, two nurses, one anaesthesiologist, one anaesthesiology registrar and two technicians), one could argue a medical student is relatively useless and their education comes second to... well everything else. In the far corners of the world (i.e. one surgeon and one nurse; if that), a medical student holds the potential of shifting the potential risks down from patient mortality to morbidity, and receiving a flood of knowledge from the surgeon. That all depends on the experience and competence of the medical student, which goes without saying.

But it's always confusing the first time. The basic assumption of fitting right in with everybody around you, who are dressed the same in every sense can be abandoned. Nurses in particular can easily tell when a rookie enters the theatre and immediately assumes the authoritative role. "Stand at least 50 centimetres away from this table. Don't touch this. Keep your hands between your chest and umbilicus. No no, go and scrub again. Hold this. Shut up." Although this could be interpreted as nurses exercising their right to power before the student graduates, it must not be forgotten that they are also responsible for maintaining infection control in an operating theatre. If you are new to the environment, you may very well be seen as a risk rather than a benefit, especially if you are only there to absorb information.

There is an unspoken language in the operating theatre and a dialect of body language that is foreign to all newcomers. It can be hard to pick, even if your thighs are hard-pressed against the operating table. For instance, there is a very particular way a nurse holds equipment compared to that of a surgeon. Equipment is given in such a way that the surgeon can use the instrument the moment his or her fingers wrap around it. This might seem obvious when written down, but may go unnoticed in the middle of surgery. If the nurse knows the operation well, they will know exactly what instrument to give the moment the surgeon raises their hand. Instruments may also appear to be simple, but often have multiple functions and surgeons almost always have multiple grip techniques.

Among all the operations I've seen and the myriad of interactions between theatre staff I've witnessed and participated in, I ask myself who's role is the most difficult. It is not the surgeon, but actually the assistant across the operating table.

To be a competent assistant, one must have theatre experience but must also know the theory behind the operation. However, due to overwhelming demands and lack of resources, the assistant usually is a junior doctor or a senior medical student. In this situation, it is very uncommon to "know" the operation and even if one knows the theory, they might not understand their role at certain phases of the operation.


How a surgeon communicates with their assistant(s) is very interesting. The surgeon asks for a retractor, receives it and places it in the correct anatomical plane. Then, he or she applies tension in a specific direction such that the relevant tissues are correctly demonstrated. Once this is maneuvre is complete, the surgeon presents the instrument to the assistant and they assume control (and responsibility) of the instrument. This process can take place without a word... The unspoken language of theatre.

Assisting requires patience but also stamina - following an operation carefully whilst holding retractors larger than one's own hands can be very painful and distracting.

Most importantly, the role demands the assistant to assume the surgeon's visual perspective whilst remembering their own. In other words: as an assistant, you must understand what structures the surgeon must see and display these correctly with the accurate application of tension on the instruments (i.e. retractor, suture, clamp etc.), even if the correct position obstructs your own field of view. The assistant's field of view comes second to the surgeons' and unfortunately, the mind constantly prioritises its own view. So you are constantly battling with your own instincts. If you apply too much tension, you damage the superficial tissues and may cause bleeding. Too little tensions results in lack of retraction. And when the medical student assumes the role of the assistant, they must avoid getting yelled at, constantly corrected and answer all questions related to the anatomy correctly - even if the anatomy being asked has nothing to do with the operation.

Remission

Doctors insist people are kept alive for as long as possible. Invasive intervention, as it may be called, can save lives, gripping the dying by their fingers and violently force them back to a life of intubation, mechanical ventilation and occasionally brain death.

Grappling Life

It is against our nature to let people pass, to do nothing. Once we investigate a patient's illness and find an incurable disease, that patient's story becomes the caring doctor's failure. The entire arsenal of medical therapy, oncology and surgery is unavailable to this patient. This is the psychology of medicine.

A new perspective is gaining popularity, which is welcomed by patients and their caring doctors... this is the view, as Professor MHK once told me: letting nature take its course.


However, cure is occasionally on the list of possible end-points, being very rare indeed against humanity's war declared against cancer. And often, I savour moments where patients are told news involving the word "cure".

Mrs. EE is a 43-year-old primary school teacher who has been in and out of radiology departments due to breast lumps. 15 years ago a lump caught her hand as she was undressing and the first ultrasound found multiple lumps, all of which were biopsied, coming back as benign (non-life-threatening) tumours. Her doctors insisted she get regularly investigated to ensure nothing changed and I'm glad they did because a suspicious lesion was discovered recently. The biopsy demonstrated a small breast cancer; it was barely palpable on examination.

Our paths were destined to cross when the consultant recommended a lumpectomy and sentinel lymph node biopsy to exclude metastasis. We met in the operating theatre, after she consented to the procedure. Like most procedures, I was distracted with paperwork and didn't notice her anxiety; someone had to fill out the pathology forms (both specimen and frozen), double check the admission form, ultrasound and biopsy results and ensure the consent forms were signed. When I turned around to see how she was, the Anaesthesiology resident had already sedated her and she was in a mixture of unconsciousness and horror.

By the time the endotracheal tube was in situ, I was already scrubbing for surgery. When I was gloved and gowned, the consultant was already drawing the incision lines and planning the procedure. After he left, it was up to me to coat her chest with iodine-based antiseptic and drape her properly. Next thing I knew, the chief resident was gloved and gowned, helping out. Then, the consultant and I were side by side and he was holding the 15-scalpel. May we start? - his routine of asking the Anaesthetic team if he could proceed; an amazing gesture of respect. He would never begin the incision before their blessing... and I literally mean their blessing.

20 minutes later the lesion was out. The blue dye he injected had made its way to the axillary lymph nodes draining the breast and the sinister tumour within it. He made a small incision in the axilla and after a few minutes of dissection, the sentinel lymph node was glowing blue in his hands. Let's take this to the Pathologist now and see what's under the microscope.

We waited as the technician made his way to the Pathologist in the operating theatre. There was a short while of pause and the only sound was the patient's heart translated into digital beeps from the anaesthetic bay.

"What happens if the lymph node is positive for metastasis?" I asked, wondering what the end point was.

If it is positive, I will perform an axillary dissection.

Spoken like a true surgeon, I thought.

Results were in - negative. There were no cheers of joy or relief. The chief resident and I were left to suture the incisions while the Anaesthetic team slowly restored the patient's consciousness. She woke up, disoriented and gagging on the endotracheal tube. Once the simple reflexes are restored, the Anaesthetics resident pulled out the tube, and maintains the airway until the patient regained full control.

Mrs. EE is different. I feel she was suffering in her state of sedation because she begins to ask whether there was spread to the lymphatic system. The theatre team dismisses it because they assume she clearly won't remember; but I'm sure she's awake, aware. Her facial expression, affect and tone of voice are telling me a story - one of desperation and fear.

I accompany Mrs. EE to the recovery ward as I do every patient and hand over to the post-operative nurses. She continued to ask about her illness. I hesitated by her side; I knew the biopsy results and for that moment, I was in a dilemma. It was customary for the chief resident or consultant to let the patient know the result of any operation. She peered in my eyes, searching for an answer.

The lymph nodes are negative for metastasis.

She cried, exhaled deeply and fell back into her temporary bed. She prayed to God for us, the surgical team, her children and her own health (in that order).

I felt a sense of relief for her, but also a sense of fear provoking me to double and triple check that the frozen pathology results were in fact negative. This was the first time I gave good news to a patient. It was an amazing feeling to provide relief to someone, though out of my moral judgment rather than my contribution to her cure. For I knew her operation would've been done with or without me.

One of the residents pulled me aside the next day. I want you to accompany the lumpectomy to the radiology department. She has deranged liver function tests and I'm concerned she has liver metastasis. Would you mind letting me know as soon as you find out?

So what? She would be known as the metastatic liver if the scan was positive? I thought... Surgeons love to define patients by their disease and refer to them the same way. It's an awful habit.

After he clarified the point Radiologists perform ultrasound scans in the hospital, it made more sense for me to attend her imaging procedure because ultrasound technicians (i.e. Sonographers) perform ultrasound scans back home.

Her husband and I walked with her as the porter wheeled her down to the imaging department. The receptionist said there was a wait, which was no surprise. Ms. EE looked up at me. 


"Your face looks familiar. Have we met before?"

Yes. We met in the recovery ward and spoke about the pathology results.


"You gave me the good news?"

Yes, I did. 


"Thank you, son."

My pleasure. We were all very happy for you. 


"You all work so hard."

I smiled. Do you know why you're having this scan?


"No, they didn't tell me much. They don't tell anybody very much do they?"

No they don't. We're here to scan your liver to make sure your disease hasn't spread there. 


"Oh..."

She was under the impression she was cured. But a new fear struck her heart and her face showed the same hopelessness as before the procedure. The pain from the wound no longer mattered and her body slumped in the wheelchair.

"Pray for me son. Please pray for me."

I am. I promise.


What felt like several hours of tension was actually ten minutes and the Radiologist finally called her name.

She was young, probably a senior resident, but she had the personality of a Radiologist from a mile away - blunt and apathetic.

After Mr. EE helped his wife to the examination table, the Radiologist looked at me as if to say "what the hell are you doing here?"

Doctor thank you for seeing Mrs. EE, who had an invasive ductal carcinoma in the right breast, which we resected via lumpectomy yesterday. She had a sentinel lymph node biopsy, which was negative for metastasis. We've asked for an abdominal ultrasound to exclude hepatic and visceral metastasis.

"Very well. Let's have a look."

The scan took about 15 minutes and I was looking at the ultrasound screen, trying to orientate myself to the anatomy.

"I could not visualise the liver in entirety, however the portion I did see was quite large. Within this portion I did not notice any lesions. The spleen, pancreas and kidneys appear within normal limits."

Mrs. EE had no idea what happened. She was too busy holding her breath and wimping from the pressure the Radiologist exerted on her abdominal wall. As her husband pulled her up, she looked at me and asked "so is there anything? Could you see anything?"

It is clear.


She cried again, almost instantaneously and pulled my white coat toward her body and hugged me. She prayed openly as we helped her to the wheelchair.

And just like that, she was discharged... there's a very good chance I'll never see her again. I'll never forget her. I hope she lives to hold her grandchildren and I pray she never has to worry about cancer again.

Sometimes... just sometimes; all the efforts, endless hours of retraction, resuscitation and intervention; demoralisation and negative criticism from the senior staff... someone comes out in remission.


And this one person, Mrs. EE, restores my faith in what I do. That not all of our efforts were in vain; that it's possible to hear the word cure and experience the joy of sharing it with the person at the centre of it all, even if it wasn't politically correct.

Volatile

I have been in the operating theatres for six of the last ten working days. In those six days, I have assisted in twenty eight operations. Some of those procedures were the straightforward, common procedures such as thyroidectomy and laparoscopic cholecystectomy; but others were on a much larger, life-altering scale. There's no such thing as a small operation, says the chief resident. What he means is there is routine surgery that's common, but all of them can potentially be life-altering and lethal.

The days have been long; it's definitely no holiday, as many people in the years above me mentioned the elective term to be. Colleagues spoke about having long weekends, half days and other luxuries. I don't quite know what they were doing on their elective, but it could not have been very productive for them. Thirteen hours a day on average with no break for food, water, bathroom or anything. Back to back, nonstop surgery. When I was not in theatre I was in the Burns unit organising admissions, changing dressings, drawing blood and sampling fluid from surgical drains. And I still can't get over the fact that general surgeons look after burns victims.

Due to the shortage of doctors, nurses have began adopting certain clinical responsibilities of medical practitioners, such as dressing wounds. So when I turned up knocking on the door of the hospital saying "I'm ready to work," they were very happy to have help. But I'm no cavalry. However, they were happy to assume that I was and appointed me responsible of the Burns unit on the non-operating days.

I was not prepared to work in a Burns unit at all. My mother told me stories of the horrific burns she had seen when I was young; and the thoughts were enough to knot my intestines enough to ignore food for a couple of days.

It was also discouraging to be conscious of my complete lack of knowledge in the management of burns. But I was and am not in any position to argue with anyone in such a system. I have been asked to serve a population of patients and it's not in my nature to discriminate, even if my stomach is jumping around like a five year old on a trampoline.

There was a stench of bandages, creams and flesh in the air. The chief resident introduced me as "the new doctor on the team" to the nurses working in the Burns unit. They had infinitely more knowledge and experience than I did; so I don't know why he felt the need to gently hint that they'd be following my lead. The nurses wore turquoise coloured scrubs that had Intensive Care stitched on the breast pocket.

After the general surgery team left to continue rounds on the other wards, there was an awkward silence at the reception desk. I broke the tension by clarifying that I would be following their lead, not the other way around. They were quite happy with that, as any nurse would be. "Okay then, wear your mask, gown and glove up."

There were ten patients on the ward and another patient in the Paediatric Intensive Care unit that required dressing changes. I followed the senior nurse into the first patient's room. He was young, and lay in a semi-upright position with his hands thickly wrapped with bandages, resting on two large pillows on each side. She showed me how to take the old dressings off slowly, so not to lift the delicate remnants of dermis and tissue along with the ointment-smothered gauze. She then proceeded to open a scalpel blade and started to remove raised, necrotic skin from the surface of the first patient, who couldn't talk. My body went numb as I watched her slice skin off the young man's arms, chest and face. I asked the patient if he felt pain with the removal of tissue and felt a little more at ease when he said no. The nurse explained that areas of full thickness burns could not perceive pain. The sensory nerve endings were obliterated.

Another nurse created a sterile field for us and opened up a few heavy sponges, saturating them with chlorhexidine. The senior nurse asked me to rub the sponges together so to create a lather and we used this to clean the patient's skin by dabbing gently. This was to prevent infection from accessing the living flesh under the eschar (i.e. dead tissue forming a scab or dry leathery surface replacing healthy skin). He sniffled in pain as he felt the sting of alcohol on exposed skin. He couldn't cry or talk because of the tracheostomy our senior colleagues provided when he came in.

Up until that point, I was oblivious as to why the patient's arms were positioned the way they were. My lack of knowledge was really frustrating me and I promised to devote a few hours of my weekend reading about burns. When the senior nurse asked me to turn his arms so that his palms were facing up, it was clear what he was hiding - the skin on his forearms and elbows were completely divided along a longitudinal incision and the underlying muscle tendons and ligaments completely exposed. When full thickness burns are circumferential, the surgeons divide the skin along these lines to prevent irreversible ischaemia to the distal peripheries. I almost passed out. Knowing the patient was conscious and awake, able to see his own underlying flesh and flinch in agony as I dabbed his muscle layers and fascia brought tears to my eyes. But for his sake, I had to put my emotions aside and focus on getting him clean as soon as possible so he could rest.

We dried his skin with clean sponges and covered all the burned flesh with cream and ointment, depending on the depth and tissue layers exposed. After that we literally draped him with gauze and the junior nurses bandaged him up.

"Was that alright?" asked the senior nurse as we got out of our gowns.

"It was fine," I lied.

"Okay then. Wash your hands and do the same with the remaining patients."

Four hours of wound dressing was emotionally exhausting. The majority of the patients were not passed their thirties and a tragic proportion of them were children.

It was awful. I felt so guilty for wanting to ignore these people out of fear of being squeamish. They needed help so very much. And I didn't realise how complex their management really was.

There's so much to learn and I do feel I owe these people a debt of volumes of study and attention. They need so much help, support and depend on us not only to survive the massive acute pathophysiological changes, but also to mobilise and return back to normal living, whatever that may be to someone who is cosmetically destroyed. The psychosocial support is the fundamental component of ensuring these people can develop hope again; and I pray that their loved ones still see the same person before them when they are released with the unspeakable reminders of survival nobody would ever want to bear.

[General] Surgery

What does it mean to be a general surgeon? In my eyes it has always been a surgeon capable of many operations involving a wide range of organ systems. "The jack of all trades, master of none" really described their work to me. However, the metropolitan hospitals in Australia had compartmentalised the specialty. It was broken down to subspecialties including head and neck, upper GI (gastrointestinal), breast, endocrine, hepatobiliary, colorectal, surgical oncology, trauma, transplantation. During their training, registrars were exposed to most if not all of these disciplines after which they could decide the range of operations they would practice for the duration of their careers. The very essence of the word 'general' was lost in a knowledge storm; an influx of knowledge impossible to keep up with.

So then, was it possible to practice as a generalist in the true sense? I asked myself repetitively. Could there be a way one could still be capable of performing a wide range of operations competently? Safely? Apparently it was still possible but limited to the rural and remote areas of the country; where thousands of people were begging for medical attention. Unfortunately the majority of doctors have consolidated into the major cities of most developed countries, leaving developing countries and country-towns up to the loyal locals... the people with the moral fibre and courage to fight against the odds.

Given my elective term is in general surgery at a metropolitan hospital in the capital of Turkey, I expected the same compartmentalisation. It could not be possible to perform a wide range of operations on such a large population. The consultants must share the workload based on the disciplines, I thought.

When I started, it was quite the opposite. The general surgical department's medical staff were divided into four groups of consultants, residents, interns and medical students irrespective of the subspecialties. Of course, certain surgeons performed more types of the same operation than others and vice versa. There were no subspecialties.

The operating list on my first day in theatre included:

1. Laparoscopic cholecystectomy, indication: cholelithiasis
2. Laparoscopic Nissen fundoplication, indication: gastro-oesophageal reflux disease non-responsive to conservative therapy
3. Abdomino-perineal resection, indication: T3N2Mx ano-rectal carcinoma 
4. Total thyroidectomy and right lateral neck dissection, indication: papillary thyroid cancer and lymph node metastasis 
5. Exploratory laparotomy and Hartmann's procedure, indication: large bowel obstruction on a background of abdomino-perineal resection for T2N2M3 ano-rectal carcinoma

I couldn't believe my eyes. After scrubbing into all of those operations on my very first day, it was clear to me: it's possible to be a 'general' surgeon. 

Hope is kindled. 

Experience vs Knowledge

We are all familiar with the eternal battle between the young and the old, the smart and the wise. In most cultures, whether or not elders have any form of education is irrelevant; what matters is they have lived, understood and gained perspective. Modern history, as we all know, is dynamic and ever-changing. Context varies from person to person, profession to profession, country to country. Two identical events happening 50 years apart have unique effects on populations, even if history repeats itself from time to time.

This morning my uncle and I took my aunt to work. The sun was barely in the sky and blankets of ice coated the sidewalk. Mum couldn't get her usual amount of rest because she's been coughing for a few days. My aunt was telling my uncle to start her on an antibiotic, despite having no formal medical education. I was in the back seat and even though my knowledge was readily available (there is no on-off switch), neither of them felt the need to ask me anything. They were more comfortable doing what they have been doing. I understood what this meant; how knowledgable I might have been was not relevant and the explanation for this was quite simple: I'm Generation Y.

I decided to respectfully protest my aunt's decision to give my mother antibiotics, explaining the concept of antibiotic resistance (mum has been on antibiotics for about a month now). She fell silent and quickly responded but it works for me, whenever I feel sick I just take a couple of tablets and I'm all better the following morning.

Despite this being against any antibiotic protocol written, I nodded politely and gently mentioned that the entire course must always be taken. She agreed, but insisted that she would feel better after the first dose.

One of my English teachers in high school taught me an interesting proverb: Experience is a hard teacher for she gives the test first and the lesson afterward. This must be the concept of Generation X to overcome the knowledge-tsunami Generation Y are exposed to.

She seemed hell-bent on feeding her those antibiotics and I know she only means to help mum. But educating a person in the previous generation is rude, disrespectful. So I sat quietly and thought about the variation in hepatic and renal metabolism of medications between people, the perception of side effects and the risk of pseudomembranous colitis due to recurrent antibiotic exposure.

Of course I cannot talk about any of this. I'm a stupid, silly little medical student who has next to no experience in choosing medications (partially true); so who am I to give advice to people twice my age? Son, we'll just keep doing what we do and in time, we'll get better.


That's the curse of being junior staff; barely anyone takes you seriously.

All in all, Generation X's perception of Generation Y is quite biased and even though some of us are outgoing, risk-taking, technical gurus; not all of us are inappropriate, or have the intention of being condescending. Either way, we've all worked hard to get to where we are, just like Generation X has to get to where they all are.

Until their perception of us change, I'm afraid very little intervention will be effective. And by the time we're old enough to be taken seriously, the next generation will be seeking our attention.

Generation Y by Generation X

Meeting

Being overseas for a couple of weeks now, it was about time I visit the hospital where my elective term will be taking place. I contacted my supervisor yesterday who wanted me to meet the General Surgical fellow (known as a head assistant) this morning. No problem, I thought.


Choosing this hospital was no accident - it's the same hospital my parents met before embarking on their journey to Australia. Dad worked as a perfusionist for a few years before moving to becoming a scrub nurse in Cardiothoracic Surgery for eight years, then moving onto Neurosurgery for four years. Mum graduated from the Faculty of Nursing here and worked in both the Emergency Department and in the Orthopaedic, Traumatology and Reconstructive Surgery operating theatres for ten years. My uncle lives quite close to the hospital and he's been kind enough to put a roof over my head during my stay here.


He explained the route to the hospital and I made my way to there with mum. Despite being sick, she insisted on coming to show me around, but I was sure the hospital had changed from thirty years ago. It was only a few kilometres and took us about half an hour to get there.


The suburb was a complex made up of a few hospitals each with their respective Faculty of Medicine. Walking towards the hospital I was assigned, the sheer number of people running around made it perfectly clear how busy the place was. I was trying to work out which hospital was busier but then it seemed obvious: every hospital is busy. The demand was always out of proportion than the supply. 

My parents adored this hospital and it was the best hospital in the capital during their careers. The corridors and stairs were made of marble with silver railings. What a beautiful sight it was. I felt happy the hospital board felt the need to make patients, friends and family feel welcome in the corridors of the unwell. Everybody spoke formally, people paid attention to each other. 


As I entered the General Surgical Outpatients Clinic (known as a Polyclinic), the atmosphere of chaos was clearly palpable. People were desperately lining up, pushing in and out with the secretaries rushing to phones, talking to staff and trying to answer people's questions. I decided to wait patiently, but everyone kept pushing in and I didn't blame them; it didn't frustrate me. In Australia, it's the opposite: it won't be busy, you present yourself to the front desk and the receptionist expresses her knowledge of your dependence on her job to ensure you see the correct doctor by making you wait while she finishes her game of solitaire. After this first impression, she asks you if she can help you as if you've irritated her, interrupting her from what she really should be doing. For the record: I haven't encountered a male receptionist thus far, so please don't take the "her" and "she" as derogatory or sexist. 


Finally, I was asked to see the receptionist manager on the staff side of the Polyclinic. She took me to the front door of the fellow's office. Doçent Dr. AK was the name of the General Surgical fellow. He was tall, showed little facial expression and had very long arms. "Doçent" is a Turkish word I haven't quite made sense of; it either means "Fellow", or equates to PhD. When I asked my father what it meant, he said the only way I know you receive the title is by performing an operation asked by an assessment committee made of up senior specialists and they watch your technique, ask you questions while you operate and intervene if you are incompetent. Either way, I knew it was a senior title, which didn't help my anxiety. 


He asked me my name, where I studied and what year I was in. When I explained I was in final year, he said:


Here in Turkey, the final year students are in fact Interns. So you will start on Monday with the senior resident. Make sure you buy yourself a white coat. Your assigned resident will give you a pager, locker key and doctor's ID. Do you have any questions for me?


I thought this would be an appropriate time to mention the difference in meaning of the word "Intern" between Turkey and Australia. 


You'll be fine. Oh and you do know how to scrub in right? 


"Yes sir, I do."

Good. You'll be expected to attend everyday. Rounds start at 0730 in the Burns Unit on the third floor. I cannot guarantee your finishing time. There will be operating lists every second day in the elective theatre. I'm very glad you're here, we are need of assistants. 


We walked up to the Burns Unit and I briefly met the senior resident. We exchanged nods and a quick word. After the quick encounter, the fellow and resident left to discuss other matters. I spent the next hour working out where the hell everything was with mum was my guide. I was grateful for her help but her eagerness to explain past times was not reassuring! 


It didn't sink in - on Monday, I was adopting the equivalent position of a Junior Medical Officer (JMO) in Australia, which is another phrase for Intern. I'm not sure if it has sunk in at all. After we left the hospital, I bought myself a white coat. 


I've spent the last couple of days wondering how it's all going to go. It's funny isn't it? In my last entry, I wrote that being in final year doesn't mean I was anywhere near ready and now all of a sudden, I'm expected to be. 


A different type of pressure is also exerting itself on my shoulders. I'm not only a guest to this hospital, I also am a representative of my Medical School back at home. I can only hope I don't look too much like a moron. And I pray I end up spending most of my time in theatre - in that setting, at least I won't have to speak or answer too many questions. If there are questions in theatre, it's almost always anatomy anyway. That sort of reminds me: maybe I should brush up!

New Look

As I look back on the year 2011, I realise how happy it really makes me to know it's last year, not the year ahead. 2012 is today and will be for the remaining days of this year. This makes me happy and I am excited to see what this year holds for all of us.

The first thing I had to do was to change the appearance of my blog because I believe the previous setup was quite bleak (for people reading my posts mobile devices, you won't notice the changes) and I wanted to started the year with a pleasant theme.

A proportion of you would describe my posts as bleak and to some extent, they definitely are. However, elements of realism accompany those posts. I wish to continue writing here, providing insight for you and I, reflecting on the things I have seen; and read my posts from time to time. One can practice medicine for all eternity and still come across a baffling history, examination and investigation result. All colleagues have a different set of experiences to each other and even if there are occasional common grounds, their perspective and interpretation of the events are still unique.

I was reading a book called The Checklist Manifesto, which astoundingly stated "there are more than 2,500 documented surgical procedures in the history of medicine." What is staggering about this is not the number of procedures, but how many variations of each procedure there are, from the pre-operative preparation, incision-site and type, to the post-operative fluid management protocols. This clearly explains the concept of practicing medicine and just because I am a final year medical student, doesn't mean I am 755 of the way of becoming a good, safe and competent doctor.

Like most normal people, I developed a number of resolutions for the coming year, but unlike most people, I didn't write them down or consider them any more than a daydream. However, I will get to that when I arrive at my residence (ironically one of the items on my list is to reduce procrastination as it can never be eliminated).

I wish you all a very happy, healthy and prosperous 2012.