Myopia II

I'm getting rather frustrated with the way O&G is run at my hospital. The lecturers keep emphasising clinical exposure time and time again since that's where the examination questions are. Yet, there are so many lectures scattered throughout the day that it's almost impossible to do so. It's my third day in NICU and I've only been able to attend one ward round and spent but a few hours with the Residents; the rest of the time we have lectures and tutorials.

A 2nd year medical student approached me recently. He knew my background in Medical Imaging and asked me to deliver a lecture on the topic to his cohort only at our hospital, as it would be impossible for me to go to every other clinical school. I agreed to start with a lecture on Imaging the Brain, the first of which I delivered yesterday. I will deliver it again tomorrow as the year is divided into 2 groups attending clinical days at different times.

I attended a lecture today on Uterine fibroids among other things and was actively thinking about Radiology as well. And I remembered a very peculiar instance of "myopia" that I experienced during my General Practice term.

It was the afternoon of a cold day early last month and we saw a young lady with concerns about irregular periods and heavy bleeding. Without going into all the details, we decided to refer her for Ultrasonography to assess the uterus, adnexa and pelvis.

A few days later, she presented with the results - images and report from the Radiology consultant. The GP discussed the results, which were normal and provided some options for symptomatic relief along with further investigations.

After the consultation had finished, he handed me the report and asked me to read it. Double check it for me will you?

So I did. It's a normal report.

He started laughing and said read the top of it again. I was confused initially and then it sunk in:

Thank you for referring this very attractive uterus for sonographic investigation of her heavy menstrual bleeding and irregular cycles.

He picked up the phone and asked to be put through to the reporting consultant.

I'm going to fax you a report you did a day or so ago on one of my patients. Please read it and call me back when you've finished.

Presumably the radiologist asked what was wrong with the report. Just have a read of it and let me know what you think.

We faxed it across. About 10 minutes later we got a call back from him.

Laughing, he said Shit... I'm sorry about that.

No problems, so long as the findings are correct. The GP shook his head.

You'll be thinking about that one for a while, won't you? And I definitely will be.

Losing sight of the objective can be so easy sometimes...

The Holy Month

This year, I have decided to take Ramazan (aka Ramadan) seriously. In fact the most seriously in my entire life. In the past, I did not understand the gravity behind it and up until last week, that lack of understanding persisted. My parents were never religious, but my mother occasionally asked me to pray for the good of all and for people. To be religious in the Turkish community in any country was in fact a political statement that the current Republic should be overthrown and replaced by an Islamic State. This is my family's view on the situation, though I know now that people can be religious for personal reasons, definitely being completely oblivious to what political they may convey.

But putting political views aside, I decided to take this Holy Month seriously because of an incident last week that taught me the true essence of tribute.

It was about 1900 hours on a Wednesday evening when I got home from hospital, "starving". Luckily I went to the local shops and bought myself some vegetables to steam and a nice piece of steak, which I was going to prepare that night.

After preparing my meal, I sat down with my plate of steak and veggies to watch the news as I do when I eat dinner. All was well until the reporter talked about the Famine in Sudan. Thousands of people left without food, clean water and walking days on end to receive aid from Charity. It was absolutely awful. There I was, sitting there eating my steak and vegetables, watching these poor people walk, collapse and die from malnutrition and dehydration.

I felt sick. I wished I could do something there and then for them. But in my current state of play, I knew there wasn't much at all I could do for these poor people.

It occurred to me that Ramazan was the best tribute to these people. My personal choice and spiritual message to them and to those around me that there are people out there in the world that I've never met and might not ever meet, who lived days and weeks without food, drink and the basics of life.

To fast means to wake up in the early hours of the morning and to eat breakfast and drink water, to pray for those without the basics and to halt food and water intake for anywhere between 12-16 hours, depending on the Lunar Calendar this year.

I am going to do every day of the 28 days. I am going to pay respect and tribute to these poor people around the world, some living here in this beautiful country that I call home.

I will remember how amazingly lucky I am to have access to a wardrobe, bed, sheets, a roof and a window. A shower, toilet and toilet paper. A towel, soap and a sink with running water... hot and cold.
I have access to a computer with internet, a chair, a desk to study and electrical lighting. I can listen to music, borrow textbooks and write with pens of different colours on many different types of paper. There's many more to be grateful for.

We are so very lucky. And if I remember these basics, like I do now every day without food and drink, I feel incredibly relieved, happy and essentially at peace that I do not take any of it for granted. That is how I pay my tribute to these people all around the world, regardless of their religion, race and gender, or any other dimension of racial differentiation.

Hopefully when the time is right, I will do more than fast to help those in need.

Clarification

My previous post inflamed Iris and sparked quite an argument over the course of the morning. It wasn't my friend that was inflamed, but my words that were inflammatory. I did ensure to write that my words did not carry ill intention or offense, but obviously I wasn't thinking it through. It compounded my bad experiences this morning in the hospital and I had no choice but to go home before I became completely distressed.

Our mutual friend who is considering leaving is someone that is much better than me in every regard. She is charming, independent and more than capable on many levels by comparison. Iris read my work and posted a response that I'm sure some if not all of you have read. At the beginning, it felt as though the response was a form of attack. A criticism that mocked my opinion and in a sarcastic tone, dismissed my reflection as childish and primitive.

The reason I wrote what I thought down in this blog was because I thought that this was an appropriate place to do it, rather than actually confronting her directly. Like Iris said, she has encountered a couple of instances where people have actually been enraged about others leaving and that's my point exactly - I am not interested in telling this person my view because there are elements of her life, as I said before, that I am unaware of. She hasn't told me and I'm sure given the nature of the friendship, I will probably never find out.

The opinion Iris has put forward to me is that this mutual friend will be capable to do whatever she wants and will be productive toward the community in the career she chooses to follow. But I didn't want to hear it - it wasn't personal toward you, Iris, I just didn't want to hear that someone is capable of being brilliant at something other than Medicine & Surgery.

As surprised as I was accused of being perfect and my expectations of colleagues is beyond the sky, I would like to respond by acknowledging that I behave this way because I am not perfect and more importantly, because I barely am of any use outside of the Clinical world.

People around me having brilliant extra-curricular hobbies and skills that I have never been exposed to before. What are my hobbies? Working on weekends. Iris, you dance and have solid faith, you cook and read. I have friends who knit, play the piano, violin and enjoy activities like cycling and sport.

This year is the first year of my life where I have been exploring the potentials to have a hobby. Yes, I'm 25 years old and no, I have not had a legitimate hobby other than watching movies or playing computer games, neither of which I do very often and I do not consider them hobbies because they are solely sedentary activities that require no effort of any kind.

I decided to join the gym, read books and enjoy teaching.

Our mutual friend has many hobbies and is brilliant at many if not all of them. She is a lovely person, an amazingly smart cookie and I enjoyed her company every moment of every day last year, when we were close. But as time inevitably moved forward, we parted ways in different hospitals and as much as we attempted to keep in touch, it just didn't happen.

Clinical medicine is all I have and I believe that for me to be so protective of maintaining its sentiment to me is natural. I have barely any hobbies and the ones I do have, I am an amateur. So when I see people 'considering alternatives' it shocks me to bits because I don't have that option. I really don't.

The patient is so important to me - the concept, the idea of delivering a service to people is critical. This is how I was brought up and it is essentially my life choice. It's the only thing I have going for me and even then, I am barely passing.

Iris, I apologise if my views were distorted, condescending or rude.

There are many other things we need to talk about, but at this point, I'll leave the arrangements to meet to you. When you're ready, when you're happy, and when you have time... perhaps we can meet.

Otherwise, I think it's silly of me to keep insisting.

Considering Alternatives

I received an e-mail from an old friend in medicine last week and it has gotten me thinking about it since. She and I were close last year, in fact quite close and I have written about her in this blog before. Anyhow, she wrote to see how I was going as we haven't been in touch in a while. Typical really. I wrote back to her e-mail the same day and I have yet to hear from her.

She told me that she was not enjoying the program and was considering other career options. She didn't have the enthusiasm and interest that she thought she might have before and if this persists at the end of next year, I will be declining my internship offer.

Speaking in the context of a Clinician, with my limited perspective, I am forced to assume that there are elements of her personal life that I am not exposed to and thus cannot adequately make an assessment of why she does not enjoy her work.

Yes, the obvious causes speak for themselves: exhausting hours, draining work and exposure to people going through a difficult journey through the hospital system, which is an emotional stress to all people who have some level of compassion and empathy. My friend definitely does.

However, after having enough time to think about it, I am quite pissed off about her attitude. I am well aware that my views are controversial and there are no intentions to offend.

Frankly speaking, the Australian Public has invested in her education through loaning money to pay her tuition in Medicine & Surgery. The hundreds of patients that have dedicated their time and through their discomfort, pain and processes of illness and or death, devoted energy to explain their history, allowed for clinical examination and provided consent to share de-identified information to other colleagues to improve perspective, knowledge and experience deserve more from a person who has signed an agreement dedicating themselves to the public.

And so with all this education she has received from the generous ill, she considers not devoting but a year of her life after the program to serve the community because of personal interests. Now like I said, I do not know her personal situation; but I do know that we all have mountains to climb, obstacles to negotiate and I sure as hell, as well as my good friends among the readers of this blog, have suffered tremendously and persisted through the program. We took the psychological damage, physical fatigue and deprivation of normal life.

So a colleague of mine, a person who is sound in academia, compassion and care has decided to consider abandoning those who helped her become who she is. In my view, I do not see how I can support such a view, especially because the purpose of abandonment is selfishness.

First and foremost comes the patient, and then comes personal well-being. This personal well-being must be facilitated to serve the patient and ensure that we ourselves do not get lost in the fog of clinical war with disease. It is an eternal war and we must not give up on patients and having said that, walking away from those who expect care is unthinkable.

Left Alone, Ne'er to Grow... Abandoned.

Eye-Opener

Obstetrics & Gynaecology has been treating me well so far. Despite my intimidation and fear, I seem to enjoy most of the experience, though I have only been in one elective Laparoscopic Hysterectomy case so far. The majority of my time has been filled with lectures, tutorials and clinical days.

The biggest setback of O&G is how to study for it. I have borrowed about 6 textbooks and only one has been quite useful with the remainder collecting dust on my desk. I got told by one of the Residents today that I had currently been studying for it incorrectly - the majority of the assessment workload is clinical rather than theoretical. That pretty much meant that about 90% of my work was 'irrelevant' to the assessments. But hey, I shouldn't let assessments guide my learning. However, if I am to prove that I am 'competent'.. I might just have to.

My last rotation was in General Practice and being back in hospital was a relief until yesterday. I was reminded of how little of my brain I was using at any given time. Of course, who else to prove that than my hero: Dr. ML - the man who tucks my tail in between my legs and sends me off into a spiral of insecurity after long case presentations.

So I organised to see him yesterday for an O&G long case. Before that, I had a morning in the Antenatal Clinic with an Obstetrician & Gynaecologist Dr. CR. There was a moment of opportunity for me to give her my long case presentation and she agreed to hear it. After my presentation, which was ill-prepared, she was completely lost in the case. In fact, the question at the end was so explain to me why she presented in the first place?

My opening statement was: Courtney is a 24-year-old female of 22 weeks gestation transferred from Victoria Hospital with epigastric pain associated with copious biliary vomiting on a background of congenital vesicoureteric reflux and myelomeningocele. 


Dr. CR's response was No no no! You haven't told me anything about her pregnancy other than gestational age!

She was right and then the comment was this case is very complicated for your first. When I discussed the patient's social history and menstrual cycle, I was told it's not relevant, I don't care.

After this, I went out to have a short break and caught up with a 2nd year colleague Anna. It was great speaking to her and catching up. We definitely have mutual respect and I enjoy her company. Then I looked at my watch and it was time to present Dr. ML my long case tailored by Dr. CR.

I enjoyed catching up with him. He told me about his experience last week as a College Examiner - I cannot understand how people know so much. I really don't. Finally the catalyst: what have you got for me?


I introduced him to the case: Courtney is a 24-year-old female of 22+1 gestation complicated by recurrent urinary tract infections and pyelonephritis with G2P0 who presents today with epigastric pain and copious biliary vomiting on a background of 1 miscarriage at 6 weeks gestation. 


Dr. ML looked at me calmly and gestured to continue.

This patient presented with what she described as epigastric pain as well as biliary vomiting, however there were no other associated thoracic symptoms such as cough, angina or dyspnoea. The pain was not radiating to any location, nor was it deep-seated. Vomiting occurred in a post-prandial pattern and may or may not be associated with a past medical history of pregnancy-related gastro-oesophageal reflux. 


There is a background of recurrent pyelonephritis secondary to vesico-ureteric reflux. The patient is being assessed by the Nephrologist for renal scarring annually. In addition, this patient was recently admitted to hospital for an obstruction of a ventriculo-peritoneal shunt, which was introduced shortly after partuition indicated by Arnold-Chiari Malformation secondary to myelomeningocele. 

He listened calmly and encouraged me to conclude my presentation. At the end, he simply said: You've given me the patient's contribution. Now I want yours. What is your differential diagnosis based on history?


I identified a few things that I thought could be explaining her presentation. But the list stopped short of about 3 differentials. I felt level with the ground again. He disliked my presentation structure.

But this is what I was taught by Dr. CR.

Dr. ML nodded. Specialists seem to have some form of undocumented myopia, where only one organ system is of their interest. What ever happened to the rest of the patient? Yes, the O&G consultant probably wanted you to dissect the components of this patient's presentation that is relevant to her, but not have been at the expense of the whole. 


That made me realise that my initial presentation structure was appropriate, especially because it was a Physician's template - the wholistic view. Dr. ML realised this: You better get used to it. You want to be a surgeon, you will have to get used to talking their language, regardless of how you feel. Just never forget that there is a person attached to that appendix you're removing that must be managed as much as the appendicitis. 


The wholistic view must never be forgotten. The patient, regardless of their presentation, must be considered a whole person - not an appendix, hernia or myocardial infarct. It's sad to see that most of medicine is becoming this way.

The Pap Smear

From Shadows to the Light of Life

The end of July has brought me to a specialty that I've long wanted to avoid in my career. Obstetrics & Gynaecology, otherwise known as Perinatal & Women's Health, is the Medical and Surgical specialty of exactly what the name describes. It is one of few specialties where consultants are actually both Physicians as well as Surgeons.. if they choose to be.

Yesterday was orientation day and we were introduced to the various sub-specialties - a firm reminder of the flooding of knowledge over the past years in all specialties as the ever-increasing demand for research persists.

Today was my first day on the wards - Antenatal and Postnatal care. Looking after women in high risk pregnancies as well as those who are about to reach labour with some co-morbidities; or simply women who have other medical issues during or around the time of partuition. I attended ward rounds and that was fine.

I was also rostered with a consultant in his private rooms to see patients. Dr. JP, a well-known and highly reputable Obstetrician & Gynaecologist, was a charismatic man in scrubs consulting but also waiting to be called to the private delivery suite for obvious reasons. He had a rare degree of compassion towards patients and I admire him greatly for retaining most if not all of it since he graduated - that takes a great deal of energy both physically and psychologically.

Jane was one of our patients, who was a pleasant 46-year-old lady presenting for a Pap Smear. I asked why she presented to her O&G for this (as it is done by GP's in the community), to which Dr. JP interjected: I'll show you.

For me, the Pap Smear is a very awkward and dignity-stripping, invasive investigation. Not invasive in the sense of complications; but more in the sense of total self submission in the lithotomy position. Dr. JP asked the patient to get changed and insisted to me that we remain out of the room while she did.

Why do you think I leave the room to let her undress when I'm going to be seeing her pretty much naked anyway?

It was an interesting question and my answer was to preserve her dignity. He agreed and expanded: in some if not most cultures, the act of getting undressed creates a greater feeling of vulnerability than actually being undressed. This was most interesting.

Yes, I had seen Pap Smears performed in General Practice, but this was my one opportunity from someone who did them as often as they do.

We entered back into the room with Jane sitting in the chair, legs clamped together with a cloth over her lap. She thankfully consented to my presence, which was not common even on my first day. The first thing Dr. JP asked her to do was to just relax your left hand for me and the result was the patient wobbling her whole arm, then placing her hand in her lap over the cloth.

What just happened? he asked me.

She moved her whole arm?  I asked in return.

Yes she did! But why?

**Pause**

At this point I had no idea what the answer was, but it's so bleeding obvious now.

She didn't fucking know where it was in space. And yes the swearing took place in front of the patient. Apparently they knew each other well.

**Pause**

Cortical inhibition. There's so much going in the environment that it is impossible to register everything, even if it is a part of you. So by asking her to relax her arm, she realised in a split second that she wasn't consciously aware of it earlier. 


Holy shit - I thought... That's amazing! But how is it relevant to a Pap Smear?

Are you wearing underwear? 


Yes. -- I'm wondering how he would have reacted if I said "No"...

Do you feel them? 


**Pause**

Yes

Ahh yes. But it took a moment to figure it out, didn't it? 


My facial expression obviously made it clear that I had no idea how all this was relevant to the procedure.

So what GP's do is they ask women to relax their pelvic floor. I asked Jane to relax her arm, an organ that all of us clearly use every moment of everyday and she had no idea where it was when I asked her to relax it. How the fuck is she supposed to know where her pelvic floor is and even if she did, how can she relax the muscles? 


**Pause**

That's why it's so painful when GP's force the speculum into the vagina, demanding the patient relax and not thinking twice about why there's so much resistance!


He tipped the chair back and Jane almost naturally assumed the lithotomy position after the end of the chair folded down. At that point, he inserted his finger and asked Jane to squeeze my finger... okay now relax. Now squeeze my finger as tight as you can.... Good, now relax. He turned to look at me.

Did you see that? She is now completely relaxed. 


The speculum caused her absolutely no pain and the procedure was over in about 30 seconds. It was absolutely amazing. Jane had a smile on her face at the end of it, knowing that nothing hurt at all.

What is the point of medicine? He asked me then.

To reduce harm and improve quality of life.

To reduce harm is one of it's fundamental principles and there are certain patient's quality of life you cannot improve. So there's more to it. 


**Pause**

It's really all about happiness. Patients need to leave here happier than they arrived and they present for two reasons: A) to be reassured they are not going to die; and B) to make a problem go away. It is not their illness that should be centralised; they must be central. What you often see are doctors getting off on the intellectual bullshit of clinical medicine and that is inappropriate because their interest is then central, meaning the illness is central and the patient is peripheral. 


It reminded me of a colleague of mine studying medicine. I asked him why he chose to do it. His response was: I enjoy a challenge and I think medicine is very challenging. Disgusted, I asked him the next question: What about the patient?

His response was: If they get better it's a bonus. 


So this was my first ever Pap Smear and it involved more than the lithotomy position, the endocervical brush and consent. It went into the depths of cortical inhibition, anxiety and complete bodily submission. It explored the importance of the purpose of medicine and the practice of these principles through compassion that lead to better patient outcomes, that is happiness rather than prognosis. Of course, in the ideal world, both would be achievable. But the practice of medicine, as I'm sure we've all seen, is far from ideal.

Dancing

The Cambridge Dictionary describes Dance succinctly: to move the body and feet to music. I have a few friends that enjoy dancing as a hobby, others as a cultural practice and definitely a form of entertainment for the dancers as well as the audience. 

What do I know about dancing? Not much - just that I can't do it for the life of me and the modern view of dancing by the majority of the adolescence may just be some form of sexual practice in public that may or may not be appropriate. Yes, that is me being judgemental because every time I watch a music video, it involves gorgeous women in lingerie thrusting their hips this way or that and I can't make any sense of it. 

My mum used to talk to me about Turkish dancing and its wide varieties, which I found interesting but not enough to make me want to learn it. I was a lazy kid. The girlfriend occasionally brings it up with me when we go out, that we can't dance very well and that we should learn. Maybe we should, but I can't make time for it... or maybe I won't. 

I'm in with one of my GP Supervisors, Dr. MT, and he asks me to take a history of a man who presents with left calf pain. He has a history of a femoral bypass on the same side, complained of pain on exertion relieved by rest, but it was unilateral. I was asked for my provisional diagnosis and I said unilateral intermittent claudication. I was right, but then I was asked then to differentiate between claudication and osteoarthritis on history, which I did successfully. After examination, we concluded that the patient, Paul, really needed to see his Vascular Surgeon again for assessment of the graft and the remaining peripheral  vasculature. Paul agreed, but was reluctant to have another operation and I didn't blame him, his medial femoro-tibial scar was very impressive and I'm sure nobody would want such a reminder of their arterial insufficiency. 

After Paul left, Dr. MT asked me about dancing... My response was quite reactive: huh? 

He then described a scenario, where two people met for the first time on a dance-floor and were now expected to dance to an unexpected tune. Neither knew each other's dancing experience, style or preference, but would subconsciously expect their posture to direct the other where to go and what to do. With the occasional smile and nod, as well as exchanging a laugh, an unknown couple would work out a way, through multiple communication methods, to synchronously move to the rate and rhythm of the tune in a unified sense to achieve harmony. At that moment, you don't know who the person is, what their beliefs are and why they are dancing with you on the dance floor. But eventually you realise, it doesn't matter... it's all a part of the journey.

At that point, I was in awe of dancers - how they could improvise and acquire so much subconscious information, process it and express it so thoroughly. It was profound and suddenly, I was thinking of how wonderful that feeling must be. 

As much as I enjoy drifting off into my imagination - I didn't grasp the significance of Dr. MT's suggestion of dancing. He waited patiently for it to click... and then it was clear to me. The symmetry was clear. 

Clinicians and patients dance together. Each party encounters the other in a foreign environment (be it the road for the ambulance, the emergency department for the patient, etc) and the ultimate idea is to establish trust, rapport to reach the same common goals of medicine - to reduce harm, improve health and through evidence, prescribe some form of treatment. 

What a beautiful symmetry!

Dr. MT was smiling. It was clear to both of us we were feeling the same sense of peace right at that moment. Of course, we spoke about the General Practitioners of today in the context of dancing. Dr. MT compared it to "Speed Dating" - in and out, getting what you want, rather than what you need. 

It reminded me somewhat of Dance Dance Revolution - a game that supposedly lets you dance for points. But it's simply compliance - it shows you where to step at what time and you have to react appropriately. So posture, communication and  harmony is lost. It becomes cold, dry and didactic - where someone (or some guideline) iterates what needs to be done. 

Don't get me wrong, I didn't say that Dance Dance Revolution was easy. Perhaps it is easier than dancing properly, but it still requires some registration and practical knowledge. 

I must also remember that it is easy for me to judge 

other clinicians, but it is important to give them the benefit of the doubt. 

All in all, this beautiful symbolism made me think of a type of Turkish/Islamic dance called Sufi Spinning, where Semazens, or known in English as Dancing Dervishes, spin in a very specific posture and meditate. 

I don't know their history, except that they have survived through centuries. Their dancing is both beautiful and profound. 

They can spin for hours and hours - it is beautiful to watch, though I have never seen them live. My father once told me about their principle, which sparked my curiosity:

Their posture (from the image on the left) shows receipt from God (hand pointing up), be it knowledge, wisdom, health or prosperity; and through them, these gifts are distributed to the people (hand pointing down) without discrimination, or any hesitation. 

And I thought: this is how we must practice Medicine. We require some acknowledgement of a higher order - God, Miracles, Science, People. We receive our knowledge, experience and wisdom through these higher orders and with these attributes, we are responsible for their distribution to the public, for the public. 

In the meantime, whilst looking after patients and continuously  learning, we must meditate ourselves to maintain our sanity. And above all else: our love and compassion for those around us must never wane.