Semester 12 - General Practice (RETROSPECTIVE POST)

My GP (General Practice) Rotation was at a Bulk-Billing Clinic in a rural Victorian Town with 2 other Medical Students. Initially I thought it’d be an isolating Experience not being in Melbourne, but in some ways it was actually nice to have GP as our final Rotation as we’d be away from the “Chaos” of the Public Hospital and the “Hysteria” of other Medical Students prior to our Final Exams, plus I could have a short Break away from my Parents who at Times aggravate me (especially when I’m stressed).

Very interestingly, all bar 1 of the GPs at that Clinic were from the UK, which in some sense made me a bit less self-conscious as I could attribute more of my Idiosyncrasies to “Cultural Differences”. Nevertheless, I told them about my AS, and they were polite and accommodating without being patronizing. In fact I swore one of the GPs was an Aspie based on his Physical Appearance and Behaviour, which really surprised me given that I’d thought he’d made the wrong Specialty Choice and burnout rapidly, but he didn’t recall so.

Communications-wise, the “Aspie” Doctor was very methodical but also displayed some Flexibility depending on the Patients’ initial “opening Speech”. He said that one should aim to give the “Golden Minute” to the Patient’s “opening Speech” because it helped Identify what their Concerns were so you could subsequently direct the Conversation in the right Direction. He introduced to me a very useful Acronym called “ICE” (Ideas, Concerns and Expectations). He told me that as long as I clarified all 3 of those Issues, the Patient would be more likely to be satisfied with the Consultation coz it gave them the Impression of being listened to, even if you have insufficient Medical Knowledge. It was one of the “Soft Skills” that would enable Doctors to sound more caring, fostering the Doctor-Patient Relationship.

The GP Environment struck me to be a lot cleaner and calmer than on the Wards. I loved that the Day started without any Ward Rounds, and I could sit comfortably, focusing on 1 Patient at a Time in a Room which created a stronger Sense of Privacy (as opposed to Curtains by the Bedside). I initially had Issues with Time-Management coz I was going into too much Detail (History or Examination - wise) out of Ignorance and Academic Interest, but became a bit more efficient towards the End of the Rotation by narrowing down the Patient’s Main Concerns from the start and then targeting that, ala ICE. It was excellent Practice for OSCEs coz of the numerous Opportunities to take Histories and Examine Patients (both Differentiated and Undifferentiated) under Time Pressure. I frequently felt like I was asking a List of Questions for Specific Issues, but had to figure out how to make it not sound so Robotic. I usually faced them and took the History in one go and gave little Responses here and there, before typing the Notes on the Computer, to facilitate the listening Impression. I was fortunate that for Clinical Depression in particular, asking about the Symptoms in itself (sleep, appetite, hobbies) indirectly demonstrated to the Patient that you truly cared about them.

The Cost of independently clerking the Patients, however meant that I had to present the Cases to my supervising GP, which was verbally Challenging. I invariably stuck to a Structure when presenting a Patient, but had to look away from the GP when concentrating hard coz the Eye Contact would actually distract me from my Train of Thought (but not painful like my pre-rTMS days).  

I think about halfway through the Rotation, I started feeling like a Waiter, asking the Patients “What would you like today? How can I help you? Is there anything else you’d like to talk about?”, and filling in Scripts and typing Referral Letters, letting the Patient comment whilst I was editing it. Whilst the Referral Letters initially seemed challenging, I actually experienced a sense of Pride in typing them, like I was the Patient’s “Advocate”. I could see myself improving over Time just by repeating various Structures. I was ecstatic that GPs could be paid for Consultations that were purely for Scripts or Referrals, it looked like easy Money, although I’m sure that the Reality is somewhat different!

I did have Gripes in that there seemed to be a significant Proportion of Patients who had chronic Medical Issues, particularly secondary to their Western Lifestyles or dangerous behaviour (Smoking, Junky Diets, Heavy Drinking, non-cautious IV drug use). According to their Medical Histories, it seemed like there was little progress by Way of actual Patient Effort to adjust their Lifestyles in Spite of repeated Appointments and Medical Advice. To be Frank at the Time I was actually very annoyed by a lot of such Patients, who invariably were on Disability Pensions (funded by the Taxpayers) for Complications of seemingly self-inflicted Conditions but didn’t complain about this openly. If these People were in Countries with less generous Welfare or Healthcare Systems, they might be dead by now. It was almost like they were being “rewarded” for chronically bad Behaviour. I wasn’t sure if there were underlying Psychological Issues that weren’t adequately addressed that may have impeded on their Compliance.

I and the other Med Students were frustrated by such “loser” chronically non-Compliant Patients. We actually brought up this Issue in a Tute with the GP Lecturer, but she then quoted from the GP Textbook “John Murtagh’s General Practice”, which VERY SURPRISINGLY stated that we SHOULD NOT TRY TO HELP THEM (!!!), but instead simplify Management Goals (as the Patient wouldn’t comply with complex ones), and maintain respectful Communication. She said that we weren’t the only Med Students to be frustrated, and that the MD Students of the ERC (Extended Rural Cohort) who have far more GP Exposure than us were already “Jaded”. She stated that not all Patients can be helped, and that you’ll eventually have to give up on some of them to minimize Burnout / Frustration, contrary to what other Politically-Correct GPs say. On the bright Side, these Patients still made regular Appointments to see the GP and Nurses, but it was Compliance with Treatment that was poor. Maybe their GPs still have the Chance to use a different Approach to positively influence them before they die, though I seriously doubt it given the Years that have already elapsed and all the Communication that’s been already documented.

In GP, you act as a “Jack-of-all-trades”, which appealed to me due to my relative enjoyment of Paediatrics and Geriatrics. As the first Point of Contact in the Community, the GP also plays a practical Role in Coordinating the Patient’s regular Care. It’s also by far the most flexible Specialty to offer Part-Time Work (including in Training), hence its Popularity with working Mothers. The average full-time Earnings seems to be much less than Hospital Specialists, but for some, the lower Pay is a Compromise for avoiding the Politics and Bureaucracy within a Public Hospital.

I was concerned whether I could handle all the Talking though, coz I was already mentally drained after 4 morning Consultations, having go back to my Student Accommodation for a Nap or sitting in Silence during Lunch-Time. I could always try to work Part-Time instead.

I was also worried that being at the “Frontline” in Community Healthcare, I could get sued by non-compliant Patients’ despite my Efforts to help them, as demonstrated by the ABSOLUTELY RIDICULOUS Lawsuit last year by a morbidly obese Patient against a GP (which eventually got overturned) who eventually developed Liver Cancer (likely as a Complication of chronic morbid Obesity). Cases like these make me pissed off, coz it gives the Impression of absolving the ***Legally-Competent*** Patient with no Physical Disabilities, any personal Responsibility in looking after themselves, penalizing the Doctors instead. IMHO it also disempowers them from taking Control of their own Lives. Had that Case not been overturned (and set a Precedent), who the Hell would want to look after Obese Patients and/or chronic Smokers then? Smokers could potentially sue GPs for developing COPD and having an impaired Quality of Life!!! Ie tons of Lifestyle-related ticking “Lawsuit-Timebombs”.

It really seems that none of the Medical Specialties are a 100% Fit for me, and that I’ll have to aim for one that best suits my Strengths, Weaknesses and Interests. Given the current Dearth of Pathology Trainee Positions, perhaps I could initially train in GP for the Job Security, and then work on the Weekends for the purpose of having a bit of Patient Contact, if I got into the former later on?! I’m not sure how feasible this is. Too bad I’m not interested in Haematology which has both Clinical and Laboratory Aspects…

Semester 12 - Surgery (RETROSPECTIVE POST)

My Surgery Rotation was done at another Hospital. I had the privilege of shadowing a senior General Surgeon, and was allowed to scrub into a few of his Surgeries.

On the Surgical Wards, the majority of patients on the Unit I was attached to, were admitted for Cholecystectomies (Gallbladder Removal), Thyroidectomies (Thyroid Removal), Hernia Repairs, Skin Cancer Excisions and Mastectomies. I didn’t get to do many Venepunctures, as the Pathology Nurse was strictly supposed to do the morning Orders. I also didn’t like how Butterfly Needles for taking blood (easier to maneuver IMHO) were scarce, with only Straight Needles being available. I really liked the Ward Rounds coz they felt very quick. As Inpatient Stay was much shorter than Medical, the Patient Histories were very abbreviated, as was the History and Physical Exam. It all seemed more succinct. The Intern and Registrar got into the Rhythm of asking about Abdo Pain, Flatus, Bowel Movements, inspecting the Sutures, and palpating the surgically operated area (typically Abdomen). Ward Rounds probably took about half the time for the same number of Patients in Med.

Scrubbing into Theatre was exciting. Perhaps it was coz I’ve never scrubbed in before (apart from 2 Operations in O&G, of which I didn’t really assist). For some reason, the senior Surgeon performed a lot of Mastectomies and Skin Cancer Excisions but no Thyroidectomies (I had to shadow another Surgeon to observe that). In the Mastectomies, I initially assisted by massaging the (unconscious) Patients’ breasts in a circular Manner to help distribute the injected Radioactive Dye (which eventually gets concentrated in lymph nodes, making it easier to identify for Biopsy), which was a surprisingly enjoyable experience. The Surgeon also suggested I palpate the Breast Cancer, which I felt to be lumpier than the regular Breast Tissue. In the actual Operation, I later got to hold the Retractors which lifted the Skin Flaps so the underlying Tissue could be excised off. The Surgeon used this Tool which created small Electrical Sparks when a Button was pushed, which burned off whatever it got into Contact with. I felt REALLY awkward when I actually enjoyed the smell of burnt Human Tissue, reminiscent of a smoky BBQ. I also had the opportunity to use this Tool, in which I zapped his Forceps that were in direct Contact with the Tissue. Thankfully both of us were wearing sterile Gloves so we didn’t get electrocuted. It was actually an enjoyable process coz every time I zapped it, the affected Tissue would fizzle and turn black. I was internally very pleased to eventually see that mass of fatty Breast Tissue get excised and “released”, revealing the Pectoral Muscles underneath.

I experienced a similar Pleasure watching the Left Thyroid get “released”, but due to my lack of any Involvement, found the Surgery more tedious to observe. I found that I had difficulty standing in one Spot for long periods of time, and was impatiently alternating between left and right of the Operating Table every 15 - 20 Minutes. I’m not sure if the other Surgeon got annoyed by that Frequency, but perhaps they tolerated it coz I wanted to change Positions to alter my View. It took about 3 Hours for the Left Thyroid to be carefully excised, revealing a large red fleshy Gland. We were allowed to Palpate it, and my, it felt warm and fleshy, but nearly the same Texture than the Placenta. It fit into my Palms, I could squeeze it like a Stress Ball!

Ironically (or not Ironically), my most stressful bits in this Rotation was the Mini-CEX. We had to pass 2 Mini-CEX’es for each of the Semester 12 Rotations. Though granted we were with a seemingly lenient Surgeon, I still felt Pressure to perform at an appropriate Level. My first Mini-CEX involved performing an Abdo Exam on a Patient and describing the Findings, in which I did so-so. The second Mini-CEX was taking a History from a Patient, followed by presenting the Information with a basic Management Plan. The second Mini-CEX felt very much like an OSCE, but in full View of my Classmates. I recall being very Algorithmic / “Robotic” when taking the History, but fortunately the Patient didn’t find it weird or offensive, and answered all my Questions. Our Conversation felt very much like a Table-Tennis Session, with responses rapidly bouncing between us. I was so mentally exhausted when the 10 Minutes was up, but the Patient and her Partner were very impressed by my History Taking. When articulating the Management Plan, I talked a lot slower coz I haven’t adequately prepared this before (verbally) + I was exhausted, but the Surgeon didn’t seem fazed. Thankfully I passed this.

I wonder that if I get drained just from just 10 Minutes of Clerking, how will I cope with Internship? Perhaps it was the Context in which I was being observed by multiple People which added to my Nervousness. It’ll probably become easier with more Experience. I realized a few more of my Weaknesses, which was in explaining Procedures and some Medical Concepts. I’ll have to work on this, or at least memorize the Explanations that are comprehensible to Laymen. The Surgeon also said that it also helps to draw Diagrams (particularly Anatomical) to aid Patient Comprehension and to get them engaged, so I’ll look into that too.

I think Surgery (along with O&G) is one of those Specialties that most People love or hate, particularly due to the long Hours. I conceptually love the Notion of Surgery, in that you’re making a Physical Difference from the Operations (removing or repairing something), which appealed to my Concrete / Black & White - Thinking Traits. However I just didn’t think I’d have the Patience to deal with the Duration of each Operation. Too much Standing, and whilst I have a strong Eye for Detail, I didn’t think the latter (along with the shorter Ward Rounds) was enough to tolerate the Former. 3 Hours just to remove the Left Thyroid. If I waited to observe the Right Thyroid being excised too, that’d be another 3 Hours in which case I’ll miss Dinner!!!

In the Past, I was even more Black & White, in that whilst I intellectually knew that an Operation wasn’t an instant Process like “Order Thyroidectomy --> BOOM --> Voila it’s gone!”, I academically treated it as such, and was unable to adequately appreciate how Rigorous and Time-Consuming Surgery was until this Rotation. I suppose if you’re the Surgeon, and if you’re very engaged and interested in the Surgery, the time may “Fly by” or be more tolerable. I can see how Surgery would appeal to a Person with Concrete Thinking, and anecdotally a lot of Surgeons in the Past (particularly Neurosurgeons) had Aspie Traits. I respect the Surgeons’ Efforts to work in this Specialty, but for me, no thanks. I want to have a Life outside Medicine. Somebody else can pursue Surgery instead, and good on them for their Ambitions. Besides, I’m currently more interested in the Diagnostics Process of Medicine of which Pathology (and perhaps even GP) is more encompassing of that.

Semester 12 - Medicine (RETROSPECTIVE POST)

Semester 12 was the “Pre-Internship” Rotations of Medicine, Surgery and GP, which I also happened to do in that order.

My Medicine Rotation was IMHO, academically and socio-emotionally less interesting than my Geriatrics Elective. The Casemix seemed narrower even though the Medical Units included some middle-aged Patients - nevertheless lots of Pneumonias, Cellulitis and GIT Bleedings. The Ward Rounds were really long, about 4 or even 5 hours as the Unit list could extend up to 30 Patients, which I personally thought was ridiculous for 2 Interns to manage. The Consultants leading our Unit were very good-tempered and polite though, which surprised me given the Patient Load. As the relevant Patients were scattered throughout the Hospital on different floors (unlike Geriatrics where everyone was on the same Ward), and these Interns were insistent on writing the Progress Notes, I quickly ran out of Patience and decided to leave the Ward Round halfway through to help with typing Discharge Summaries instead, which was still time-consuming but engaging. I did appreciate the Venepuncture and IV Cannulation Opportunities I got during this Rotation, and was enjoying the process of collecting Patient Stickers from the Pathology Nurse and taking Blood Samples / inserting Cannulas. It was a bit like an Adventure hunting down Patients to intervene on. I probably did about 30 Cannulations and 50 Venepuntures in this Rotation. It felt gratifying to put Test Tubes into a Container which got placed into a Chute to be suctioned to the Pathology Department, “Futurama” - style.

Two interesting Cases though. We had a Bedside Tute and the enthusiastic Registrar showed us a Patient who had Janeway Lesions on his hands, which are flat painless skin lesions following prolonged, undertreated Infective Endocarditis. To be honest it didn’t look that remarkable, but because this Clinical Sign is so apparently rare in Australia (maybe except Aboriginal Communities) that we would probably never see one again for the rest of our working lives.

Second Case was a young Autistic Man who was very agitated on the Wards. I found it particularly unusual that his Expressive Speech was approximately that of a 3 year old, yet at one point during his Meltdown, he rapidly said "Our Conversation is Over". At the time I wondered if they neurologically have the Capacity to acquire significant Vocabulary and other Information, but are unable to retrieve / integrate it efficiently due to inefficient Wiring, almost like he was "trapped" in a sense? I managed to calm him down by squeezing his hands and forearms, and also stroking his back or arm repetitively with his Soft Toys, and talking about his Special Interests, hence reducing the need for Psychotropic Medication on that Day.

His Mum was pleased and complimented my Actions to the treating Team.

I think this Medicine Rotation further emphasized the Notion that it’s not necessarily the Medical Specialty that influences your enjoyment of a Rotation, but also the Staff within. Particularly as this Rotation was even more bread-and-butter than Geriatrics, I still looked forward to each Day coz the Interns were otherwise friendly and very appreciative of the Help that I provided, and were willing to give little bits of Advice here and there.

Geriatrics (Part 3/3, RETROSPECTIVE POST)

I was trying to gain as much Experience as possible prior to my Semester 12 Rotations and (deferred) Internship with regards to Paperwork and Physical Exams (Visual Acuity, UL & LL Exam, also Ankle-Brachial Pressure Index), and was very proactive in asking the Interns and Residents for Things I could assist in. Part of me wonders if my Motivation to do all this was also to please and be liked by Colleagues? I didn’t want to be known as a People-Pleaser, but having been through my horrible Childhood, wanting to gain Approval was quite tempting. Is this low Self-Esteem or Insecurity speaking? The more things I did for them, the happier they seemingly became, and I became even more motivated to help them. It was like a Positive Feedback Loop. It was almost as if I was doing the Extra Work not because I wanted to bend over my back to help the Patient, but because I wanted to help the Doctors, to do something important and be valued by them.

It was during this Elective in which I frequently came to the Hospital on the Weekends to work on the Draft Discharge Summaries. The Nurse Unit Manager was so impressed by my Diligence that she even bought me a little Cake the following Monday, which I wasn’t able to eat coz I was at a Medical Appointment IIRC. On the final Day of the Elective though, the Registrar actually told me that whilst she appreciated my Efforts to be helpful, I needed to look after myself as well, and that it was important to rest on the Weekends when off-duty for the purposes of sustaining yourself.

Doctors are Human after all, they’re not G-ds or Machines, and they also need to have their Physical Needs satisfied, so they’re more likely to perform at an appropriate Level when at Work. Interestingly she also said that there wasn’t much Point in doing all these Discharge Summaries for Internship Preparation coz she believed I was going to forget all of that Knowledge, and would be better off learning it soon before/after Internship started. She believed that I was taking a long time to complete the Discharge Summaries coz I wasn’t the main Doctor looking after them, and thus wouldn’t be able to recall the Patient’s “Story” quickly off the top of my Head. That may be true, but I was also concerned that it was also due to my intuitively reduced Ability to see the “Big Picture” and instead process all the Medical Issues and Management as little Details, thus bogging me down. I’ve identified a possible weak point and will explore this later on.

She also said it was a common Phenomenon for new Interns to go through a Phase where they get paranoid about the Medication they’re prescribing, that it might accidentally harm the Patient, eg “Panadol causing Acute Liver Failure” even though people buy it Over-the-Counter at Pharmacies and use it all the time. It was comforting in that I wasn’t alone. My Experiences during this Elective really hit me, that if uncontrolled, I could easily go overboard with Work, which is facilitated by the Aspie Hyperfocus Tendencies, and let Medicine take over my Life. I will need to actively recognize and set Boundaries in order to maintain a Work-Life Balance…

I was extremely satisfied from my Geriatrics Elective, not only from the Patient Aspect (as with Paediatrics), but from the Staff who I interacted with. My Impression is that how much you enjoy a Rotation can also be influenced by the Staff (Doctors and Nurses) you meet from that Specialty. I appreciated that the Staff made the Effort to help the Patients each Day even though the Recovery Process frequently seemed rather slow. In Fact, a Handful of Patients I met at the start of the Elective were STILL at the Hospital when I was nearing the End!!!

From an Academic Perspective, I’d strongly recommend a Geriatrics Elective for Medical Students who aren’t sure what Specialty to do an Elective in, given the high prevalence of elderly Patients in Hospitals, or want to gain some Generalist Experience in “General / Internal Medicine” but with a “Twist”. It’s very eye-opening and heart-breaking at Times, but one could learn a LOT, both Medically and Socio-Emotionally.