The other the same

It seems as though I’ve seen a lot of people dying recently. Dying as a verb – breath gasping, limbs seizing, guts retching; dying as a noun – interrupted, ventilated, brain dead. After all this time in hospitals – the medical student in the corner witnessing silentlyish the tragicomic human mess – I wonder what I’ll feel when it’s me or my loved ones. Will I feel it for real, or will it seem second-hand, as if I’m remembering something I saw once in a film?

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Why do we become doctors?

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Another blogger wrote a lovely post recently about some of the challenges of being a medical student, and about her motivations for doing what she does. It reminded me of all the times I’ve wondered the same question.

Medicine is hard. Really, you say? Didn’t we tell you that before you started? Well yes of course, and I knew that and yes, I heard all those doctors who told me not to do it. I’m not deaf. I’m not stupid.

Medicine has been hard in ways I didn’t expect. The work is pretty full on, yes, but not really harder than another degree. Worse has been learning to be a student again, summoning up motivation to study, and exchanging friends for textbooks. And while medical school is one thing, I suspect working life will bring additional…issues. I’ve recently applied for my first Foundation doctor job, a national process that gives final year medical students a vague illusion of choice and autonomy before corralling them into random hospital posts across the country. That’s how it feels anyway. I find myself resenting this process heavily, given that as a… mature… student I would quite like some say in where I settle down for the next few years.

And of course it will continue to be hard. More exams, more job applications, more relocations, less time with partners, friends, children…and of course the sheer hardness of being a doctor at all. Of remembering all the blood results of every patient on your ward in case the consultant asks. Of knowing what to do when you’re the doctor on call and someone stops breathing. Of working out the real reason Mrs Singh has come to your GP clinic and managing her 26 differing needs in a way that is sensitive and appropriate and evidence based.

And to think I used to have jobs where all I needed to do was turn up at 9:30 (9:30!) and switch the computer on.

So why do we do it then? Is it because we “want to help people”? It’s the obvious med school interview answer, but you can help people as a plumber, teacher, hairdresser, kid’s party entertainer, politician – and have more time for your family. Is it to get rich? Better to choose banker, oil company executive, footballer’s wife. Is it because we love science? The thing is, medicine isn’t science, not really – you’d be better off in a lab.

For me, well I’m still not sure and the answer will probably keep evolving. But it probably involves needing some kind of job due to not being an heiress, being nosy about other people’s lives, the rush of a busy shift on call, the amazement of seeing a brand-new baby or someone’s insides, the daily ethical dilemmas, the joy of getting a thank-you kiss from an old lady, the satisfaction of making a diagnosis, the sheer daily variety and, yes, knowing that – even if it was just for an instant, I definitely did make a difference to someone’s day. (It could have been a net negative difference mind, but hopefully not).

It’s interesting, isn’t it, that at the end of the day we often make emotional rather than rational decisions about the most important things in our lives. I didn’t make a rational checklist when choosing my boyfriend – most people would agree that to be weird.

I know that as a medical student I still have a somewhat unsullied view of the daily grind. If you quote this post to me one 6am when I’m about to start my hour-long commute to work having been up all night feeding the baby, you can expect to get a slap. But I will try to thank you afterwards for reminding me.

I’m a GPeeee!

Yep, I’ll admit it. Part of the reason I’d been looking forward to my GP placement is that GPs sit down all day, right? And they start late and finish about 4 o’clock, right? And they drink loads and loads of tea.

Uhuh.

I’m halfway through the placement now, and the day goes something like this.

Wake up, jump on bike, arrive at GP, weave through epic crowd of patients, walking sticks, pushchairs etc in waiting room, hoping that none of them are already on the lookout for me. Find consulting room, log onto computer, find GP supervisor, scan first patient’s records, call in first patient, listen to description of sore back/palpitations/cough/noisy neighbours/insomnia/incontinence/unemployment/divorce/pregnancy/itchy toe, ask semi-informed questions relating to symptoms, rack brains to check for obvious missed things, smile, examine back/chest/abdomen/toe, write in notes, ask about ideas concerns and expectations, check BNF, discuss options, ask questions, explain medications, call doctor, present history, write in notes.  See next patient, do neurological exam, explain difference between tension headache and migraine, try to allay anxieties about medication side effects, calculate BMI, check appointment list, apologise to next patient for lateness, listen to chest, look at tonsils, take temperature, print diet advice, call the doctor, breathe. Feel a pulse, take patient for ECG, diagnose atrial fibrillation, discuss management with doctor, explain different anticoagulants to patient while doctor writes referral, pass tissues, make small talk about patient’s son who is training to be a doctor. Think about that cup of coffee. Join doctor on home visit, take blood pressure, write in notes, play with the dog. Drive back to surgery, grab lunch, mainline coffee just because I finally can. Return to consulting room, call in next patient, repeat.

The thing is, I was looking forward to this placement a lot; I always thought I’d like GP and I was interested to see how the days would be. I like people’s stories. I like that every patient has a social or psychological side to their presentation, and that that stuff matters to the GP. I like that I have responsibility here – my own list of patients each day who I see on my own. I like that when I say I’m the student doctor people actually nod and stay in the room, and even listen to what I say. I didn’t realise how crazy busy it would be though. I take my hat off to GPs. The job is phenomenally grinding and complex and they work their socks off. I don’t know if I could do it forever, I don’t know if I have it in me to care enough, in ten-minute slots, about every sore foot and infected finger and sleepless night that walks through the door, and then to be on-the-ball enough to pick out the cardiac arrhythmia, the sick baby, the case of cancer and do something in time. It remains to be seen if I can do that.

The thing is though… here’s the thing: when I get home each night, and stop to think about it, I have had an awesome day.

In praise of geriatrics

“Is that physio coming back today?”, asks Mrs Jones in bed three. “The dishy one? Oooh, he was so tall and dark. The most handsome young man you’ve ever seen.”

Mrs Jones is 91. “This is one of the many great things about geriatrics”, laughs the consultant. “You don’t hear this stuff anywhere else.”

I’m doing a three-week ‘career experience’ in geriatrics, and it’s great. It’s one of the fairly few specialities where you have to be a real generalist – old people come into hospital for lots of different, often interconnected, reasons. Perhaps they come to A&E because they’ve fallen over at home and broken their hip, but the geriatrician’s job is to work out why they fell and try to treat the cause. Did they have an arrhythmia, an abnormal heart rhythm? Does their blood pressure drop too much when they stand up? Are they unsteady on their feet because of cerebrovascular disease or Parkinson’s or arthritis? Do their medications need adjusting? Or is it just that they can’t see properly and their house is a bit cluttered? I love detective stories, so this kind of medical sleuthing really appeals.

It also takes more than just doctors to do the job. There’s no point in fixing Mrs Jones’s broken hip if there isn’t also a dishy physio to help her learn to walk again, an occupational therapist to make sure she can manage at home and a social services team to arrange carers to come and see her. And you have to care about people’s whole lives, not just their illness. What kind of house does Mrs Jones live in? Are there stairs? How many? Where? Who is at home with her? Does she have a husband who can help, or is she the one looking after him?

People say geriatrics must be depressing because your patients are old and so many of them will die. I don’t really see it like that though. We will all die, but these are people to whom small things make a huge and immediate difference. Like Mrs O, age 89, who cried with happiness the first time she walked again after her hip operation. Or Mr H who didn’t mind being in a residential home as long as it was close to his friends. We seem to fail so often in this country, in the way we treat our elderly. We need to get these things right – our parents and grandparents deserve this.

Of course there are sad things. My constant lament – that people come into hospital with some minor ailment and end up diagnosed with something worse – is ever present here. Like Mrs B, who complained of constipation and ended up with metastatic cancer.

And it is ethically fascinating. As my consultant says, “You can’t get as far as breakfast in our society without having to make dozens of ethical decisions.” And geriatrics is the same. Geriatricians decide on a daily basis whether patients can give informed consent for a treatment; when a procedure is in someone’s best interests; when it’s ethically right to withdraw active treatment and allow someone to die.

Mrs Brown is 95. She came in several weeks ago after a fall in her nursing home, and then developed pneumonia. She is frail and sick, and has dementia, and her family want her to be allowed to die peacefully without any more aggressive treatment. My consultant agrees, but for some reason she has been started on antibiotics anyway.

Mrs Brown has fallen to one side in her hospital bed, tiny against the pillows. A bag of antibiotics hangs from a drip stand by her bed, snaking into a cannula in her hand. My consultant tries to rouse her but she doesn’t speak, just grips his hand in both of hers and doesn’t let go. “It’s frustrating”, he says. “What benefit are we giving her with these antibiotics? Take them down. Take the cannula out.” He turns back to Mrs Brown and squeezes her hands. “Are you alright? Is there anything I can get you?” She opens her eyes for the first time and smiles. “Can I have a nice cup of tea?”

 

 

 

 

Servicing the giant revolving door

I had hoped to spend my elective in some busy general hospital, seeing terrifying things and learning a lot. It hasn’t really turned out that way, but my time at the river clinic is showing me something else instead.

This is ‘GP land’, as they say at home, but with little capacity to do anything beyond the basics. No friendly ambulance a phone call away; few diagnostic tests. GP land in extremis. Sitting at the doctor’s table in our one-roomed floating clinic, I watch the local villagers as they come in – often barefoot, mums breastfeeding, stooped old ladies, kids staring wide eyed at the strange white doctor. Some are really sick; others are here for their weekly health check, taking advantage of the free clinic and its medicines.

Often the doctor and I have three sets of notes at once as a young mum presents her runny-nosed toddler, her feverish baby and her own painful abdomen all at the same time. We see lots of common things – a boy with bacterial conjunctivitis, an elderly woman with a painful hip, a small child with a chest infection. Our tools are a stethoscope, auroscope, pen torch and The Oxford Handbook of Tropical Medicine. The contents of the drugs box have been selected carefully for the setting – metronidazole, ciprofloxacin, albendazole, paracetamol, oral rehydration salts.

I can see how useful the clinic is, in this location so far from any other formal health care, but from a medical perspective I find it quite frustrating. Perhaps I’m too inexperienced in primary care. I wonder how many people here have HIV and other STIs, and realise that probably nobody knows.

A young woman presents with vaginal discharge, and the doctor asks me what I think we should give her. “Well…what colour is the discharge? Is it itchy?” I can’t speak Khmer, so the doctor is translating the histories for my benefit. “She says it’s clear, and a bit itchy. What do you think?” I’m not feeling great about this. Even if I wasn’t just a medical student, I’m pretty sure I’d still be reluctant to make a diagnosis based on three words: ‘clear’, ‘itchy’ and ‘discharge’. “Can we have a look at it?” I ask. “She doesn’t want to show us”. I’m not really surprised. Anyway, the team dentist is seeing another patient behind the curtain. “Can we ask about sexual partners?” “Well she’s married”. “Is her husband likely to have other sexual partners?” “Sure. But we can’t ask her that.”

In the end the girl goes away with metronidazole and clotrimazole to cover all bases, and I’m left with a sense of futility. Without knowledge about STIs, and without her husband’s co-operation, she’ll be back again and again and again. I realise that, without good public health and education, doctors are simply footmen servicing a giant revolving door. In a way it’s why I like general practice so much – through patient education, primary care doctors get to prevent illness, or at least treat it before it gets bad. It’s frustrating to see a situation where there are so many obstacles to health.

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Some basic taxonomy

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Exams are back. Or, we’re back at exams. There are a few distinct species of medical student who emerge at this time of year. Here’s your handy guide to recognising them:

The super-competitive one.

Says: “I was in the library ’til 1am last night, then my housemates and I went through all the Parkinson’s plus syndromes before practicing the hip, knee and elbow examinations. Do you know the chemotherapy regimens for myeloma? They’re easy, I did them this morning.”

Found: on the ward or in the common room, discussing rare syndromes with other members of same species. Usually wears shirt, ID badge, stethoscope and smug smile.

The self-depreciating panicker.

Says: “Oh my god, I’m definitely going to fail. I spent all of yesterday looking at cardiology and I can’t remember ANYTHING!”

Found: in the library, semi-visible behind huge pile of books, notes, highlighters and can of energy drink. Wears stressed expression.

The overly nonchalant one.

Says: “Oh yah, whatever, I never do that much revision. I was playing rugby/trampolining/running a half marathon yesterday. I got 82% last year though.”

Found: having a coffee and chatting loudly at table next to self-depreciating panicker.

Note: no matter which species you identify with, or even if – god forbid – you think you’re normal, it is never ok to adopt either an a) non-competitive or b) contented demeanour. Think revision sucks but you’ll probably be ok? Nope, no way. It’s just not said.

Me? Well, I’ve clearly developed a fetish for post-it notes and have pink and green spots swimming in front of my eyes. Now, what’s that syndrome called again?

 

Bedrest

The patient limps through the door and eases himself into the chair by the surgeon’s desk. I’m sitting in on a private orthopaedic clinic. I’ve only been here ten days, so my Amharinya is limited to things like ‘thank you’, ‘coffee please’, ‘no’, ‘yes’, and that strange sharp intake of breath that means yes.

This man is obviously in pain though, and the pelvic x-ray tells me why. He has avascular necrosis of the hip – his hip bone is wearing out.

I listen to the surgeon taking a history, pointing at the x-ray. The patient nods, shakes his head, looks tired. Eventually the surgeon produces a pad and writes out a sick note. I peer over his shoulder.

“He needs bedrest.”

The patient nods, takes the note, limps out.

“Bedrest?” I say. This is nothing I’ve learned before.

“Sure”, says the surgeon.

“Of course what he really needs is a total hip replacement, but he can’t afford it. He works as a security guard, so all I can do is tell them he needs bedrest, and at least then he can take the stress off his hip and he’ll be in less pain.”

Bestrest, not surgery. Just a single moment, a tiny glimpse for me. Here, a daily reality.

Audacity

Have you ever started a sentence and realised you have absolutely no idea where it’s going?

Yesterday I found myself sitting in the Dean’s office, in the biggest university hospital in the capital of Ethiopia. Huge, shiny table. Award certificates. Business card holders. The Dean is a thoracic surgeon, for Chrissake. Very Good English.

“So, what can I do for you?”

Did I mention that this trip was somewhat fly-by-the-seat-of-my-pants? I suddenly feel a wave of guilt at my own audacity, that I thought I could just walk into this hospital because I’m a medical student and I felt like it. I can feel myself blushing. Deep breath. I got this far, I think. Don’t be intimidated by a shiny table.

I tell him who I am, some approximation of why I’m here. I can hear myself as if from outside. Am I being completely ridiculous?

“So I hoped it would be possible to spend some time in the internal medicine department.”

He looks at me for a long moment.

“Of course! Welcome. Anything you need, just let me know.”

I breathe again, grin, and shake his hand. I often have a suspicion that much of medicine is about bullshit. This is just practice, right?