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.

Self Directed Learning (as opposed to Didactic Education)

I should’ve posted a few months ago, but I was busy with other tasks and was “procrastinating”, my apologies. I hope everybody has had a safe and happy Christmas (or another festival if you don’t celebrate Christmas) and New Year’s Day.

This is a relatively controversial post, certainly among the medical academic staff and students, but I can’t resist my thoughts any longer, and I refuse to shut up and be “politically correct” in this regards. I’ll type about less “bitchy” things later on.

I’m rather disdainful of the concept of “Self-Directed Learning” in Med School, as I personally find that for me, it is counterproductive and obstructive to my optimal acquisition of knowledge, and I get frustrated by it. Yes, there’s definitely an element of personal responsibility in studying and putting in the effort to visit patients, speaking to them, and writing your own notes, but I feel that the burden has been placed way too much on the student, with insufficient guidance from the main medical faculty.

To put it in simpler terms, the concept of “Self-Directed Learning” primarily involves med students planning out what topics to learn and to what detail, with less didactic education given by lecturers/tutors in past medical curriculi. While this may sound simple and practical, this is far from the truth for me (and possibly many other students). A major issue is that the field of Medicine is so broad, and that there are so many medical conditions to learn, and so many textbooks, websites, medical papers discussing them, it’s hard to gauge which medical conditions should be studied (besides the really obvious ones like stroke, diabetes, cardiovascular disease, epilepsy), and how much we should know. I do receive handbooks for each of my rotations, but from experience I’ve noticed that other “significant conditions” that get discussed by consultants are sometimes not mentioned in it, instead including more “rarer conditions” instead! Also the handbooks don’t give a generic idea on what boundaries we should learn up to, before it becomes excessive/overkill. There are a few objectives that are vaguely stated, but I find this to be insufficient, especially when they don’t even tell you the steps on how to do it.

As an Aspie medical student, I have a much stronger tendency to process information as details and have trouble seeing the big picture (not just medical academics, but in social situations and generic reading comprehension for fiction). I also have a strong tendency to want to know a lot of details about the particular aspects of a medical issue, because I feel uncomfortable simply memorizing facts and I want to know the deeper aetiology/physiology/cause. I was aware that you don’t need to know, eg, 10 pages of the genetics of Marfan’s Syndrome, but it’s very hard for me to modulate how much depth of each section to learn. I feel guilty and uncomfortable if I only learn a few sentences about one aspect, and I feel like I’ve wasted my time if I learn too much about something when it’s not going to be examined or used (in a pragmatic sense) in the clinical setting for a JMO (junior medical officer).

I get frustrated by how each block is “only” around 6 weeks long comprising of 2 - 4 medical specialties, eg Haematology, Gastroenterology, Cardiology, and yet we’re somehow meant to learn the major conditions for those specialties in that time limit, without them telling us which is more important and how much. IMO 6 weeks is barely enough for 1 specialty, let alone 2-4. It feels like a very strenuous task, and later in the Semester, I tended to spend more time in the library trying to type notes on a condition (that might be trivial but still mentioned in the exams from experience) when I personally would much rather spend more time on the wards trying to practice my Clinical Communication skills and Physical Examination techniques with patients. I feel that I’m eating, sleeping and shitting Medicine and studying inefficiently through insufficient guidance when I could’ve had more time to talk to patients or even spare time for myself. I was very tired, and may be really tired/burnt out again when I start my next Semester.

People have told me the following - “If you don’t like the course, then leave.”

- “This is how your Uni arranged the curriculum, just accept it. Who knows, in 50 years’ time, the curriculum will change again, and the med students then will have to accept it with their heart.”

- (even more insultingly) “Suck it up, you’re just not trying hard enough.”

- “Self directed learning is to prepare you for the workplace, where you’re not getting spoonfed anymore.” (this operates under the assumption that everyone has adequate insight into the clinical setting + medical issues, which isn’t necessarily the case)

It’s not just frustration for my own comfort at the moment, but also for my future vocationally-wise. I DON’T want to end up accidentally hurting a patient through negligence of certain information coz I was spending so much time learning more trivial minutiae in med school. WE'RE LOOKING AFTER PEOPLE’S HEALTH/LIVES. The generic purpose of the Medical course is to prepare medical students for Internship, where they start engaging in “paid” service-provision in the care of patients, under the supervision of more senior medical staff and working in cooperation with nurses and other allied health people. IMO I don’t think the current medical course (maximally) efficiently prepares students for internship given the lack of practical guidance, and there’s a risk that students may spend too much time studying topics and details just for the sake of passing the exams, as opposed to improving their functioning on the wards. Yes, the work is applied knowledge, and medical information gets updated all the time, and yes I don’t expect to be completely spoonfed, but I really think that at the stage of a medical student, the faculty should provide more clear-cut guidelines so everyone can learn the imperative basics before moving on and learning things independently as they become more senior medical staff. Now, it’s all a mish-mash, VERY wishy washy and nebulous.

There has been speculation that some medical faculties are emphasizing on “Self-Directed Learning”, and not breaking the medical subjects down into more specific categories (eg Anatomy. Physiology. Pharmacology.) and teaching it didactically coz they wanted to save money. I can’t comment on that, but if that was true, then I’d be very disappointed. However, there were a few studies, starting from Canada, which came up with findings that “Problem-Based Learning” with a weekly-based medical issue is somehow a superior way of learning medicine compared to previous didactic styles, but I’d like to digress as I don’t think it that alone sufficiently addresses the amount of information we need to know, a block having 6 X weekly medical issues when the handbook contains 40+ (and probably at least 10 more that aren’t listed), ie not a complete substitute. The studies may show it works, but in practice I don’t think it’s noticeably superior.

Ideally I would prefer to receive extra time for each medical specialty (at the expense of graduating later), and/or be told directly what the main issues are along with generic boundaries for med students in their clinical years.

Compensation strategies (outside of official sources) that I have used include:

- Limiting myself to 2 or 3 pages for each medical condition, (painfully) forcing myself to limit each section (eg Symptoms, Investigations, Treatment) to a specific textbox.

- Limiting myself to only 2 or 3 textbooks, a major one being “OXFORD HANDBOOK OF CLINICAL MEDICINE” which happens to summarize the information for me (so I don’t have to figure out how to summarize it).

- Speaking to patients a certain number of times each week (but have to moderate it, otherwise I’ll be “occupying” too many patients and not giving other classmates a chance).

- Asking a family friend (who’s a doctor) for help, he tells me what’s important and what conditions I should just leave til I’ve covered the others.

I hope these strategies work for now and the future, but I’m somewhat displeased with how things are going atm. Even then, me artificially restricting myself as a preventative measure to avoid learning too much about each aspect of the condition may prevent me from gaining sufficient knowledge of areas that might need to be learnt to a deeper depth. I feel like I’m going to become a super duper Jack-of-all-trades just to cope, the lowest of the low : (

We'll see what happens for this Semester...

Experiences and Impressions from Clinical School (Part 3: Clinical Patient Interactions)

Patients Concealing Anxiety and Depression

I’ve observed that a lot of the patients could openly talk about their physical medical conditions (and Diabetes), but are reluctant to talk about Depression or Anxiety. They might even “lie” about feeling happy and calm, which was contrary to the notes in the patient file which indicate a prescription for antidepressants and sometimes note “panic”, “sadness about [XXX incident] happening”. I’ve already memorized some facial expressions and certain body postures of NTs which typically imply certain feelings, so I try to observe the “upset” one in the patients when seeing them speak. I was told by a friend (who is NT and usually sees patients with me) that mental health and psychiatric conditions are often stigmatized by the majority of society and tend to get hidden away should it be regarded as a “personal failing” or a “mental weakness”, and that they chose to be depressed/anxious.

Furthermore we were taught in a tute that to perform a Depression screening, you have to ask questions which sound like they’re not related to Depression, but are actually factors of it, as many of the patients apparently don’t like to be confronted with the direct question “Are you depressed?”. Eg

“How has your sleep been recently?”

“How’s your appetite?”

“Are you looking forward to anything after leaving the hospital?”

“Do you still enjoy [YYY activity] these days?”

and in the worst case scenario, you may ask “Do you ever feel life isn’t worth living anymore?”

I find it disappointing that society at large seems to stigmatize mental health/Psychiatric conditions and perpetuates the pressure on people with Depression, Anxiety etc to hide how they truly feel and act cheerful and complacent just to keep up appearances and not “ruin the atmosphere”. I wouldn’t be surprised that such suppression of how one truly feels for fear of ostracism/”punishment” upon open expression would exacerbate their mental health conditions even more. It’s also possible that some people feel that Anxiety and Depression is something to be ashamed of and it’d hurt their pride if they revealed it and/or it'd affect how people viewed them, but I feel that society’s prejudice plays a factor into this impression. Apparently this phenomenon is even worse in Asian countries, where society is more hierarchical and conformist and there’s a greater lack of mental health and psychiatric services.

Other Notable Patient Encounters (fake names used)

“David” (dead son has undiagnosed Asperger Syndrome): David was in the hospital waiting for an operation. After asking him about his history of presenting complaints, I asked about his family. He said that he had a son who left the home and committed suicide at age 41. I told him that I’m sorry to hear about that, and asked if he happened to know why his son committed suicide. He then said that his son said he “couldn’t take it any longer” and that his son displayed all the clinical traits of Asperger Syndrome.

I told him that I had been diagnosed with Asperger Syndrome and asked him numerous questions regarding his son’s childhood and adolescent years (with his consent). His son had a mild speech delay, narrow interests, and would spend hours upon hours reciting scripts from Shakespeare at the age of 8, could do calendar calculation, hated eye contact and soft touch, and had difficulty forming reciprocal friendships with NTs. His son got bullied a lot at school, and even when sent to a boarding school where there was routine, got ostracized by other NT students. He also went to TAFE but dropped out due to not being able to tolerate the social atmosphere.

I explained to him that Asperger Syndrome was a relatively recent diagnosis (introduced in DSM-IV in 1994), and that the concept of an Autism Spectrum was very unheard of prior to the late 80’s/early 90’s, and that the clinical definition of Autism was much stricter prior to that time (predominantly classifying Classical/Kanner Autism), hence most people who now have Asperger Syndrome went undiagnosed throughout their childhood and young-middle adult years and deemed as “weirdos” or “nerds”, or they get misdiagnosed with Schizophrenia, Childhood Schizophrenia, Bipolar Disorder, Borderline Personality Disorder etc and get medicated/treated incorrectly, to further detriment of their cognitive functioning and emotional wellbeing. I told him that due to the huge lack of awareness of high-functioning Autism and Asperger Syndrome before that period, it wasn’t his fault nor his son’s fault regarding the tragic suicide, and that had his son been born much later (circa 1995), he would’ve easily received the Asperger Syndrome diagnosis by age 15 and received the appropriate support and accommodations at school.

David understood everything that I told him regarding this issue and didn’t say he was offended or upset about it. He understood that it was just bad luck that the condition wasn’t known then, and that to grow up and live as an adult with all these social stresses and being constantly pressured to put up a façade of “NT normality” even though that’s against his pure behaviour, difficulty with executive functioning, multiple phases of unemployment due to constant workplace bullying by intolerant NTs and not knowing what the cause was, would be traumatizing and lead to suicide.

For me, the death of David’s son was concerning as this was an example of the reputed “Middle Age Autistic Burnout” where an unsupported ASD individual is typically pressured on a daily basis at work (at a workplace with superiors who are unaware or intolerant towards ASDs), with “friends” or in public to be a “square peg in a round hole”, to fake their social skills and behaviour to primitively simulate an NT to avoid bullying, discrimination and getting fired for trivial issues not directly related to the work. It eventually becomes too cognitively exhausting and their coping mechanisms are eventually insufficient, so they reach an episode of severe depression and fatigue, and are no longer able to work in such oppressive/conformist environments anymore, and often quit their job, become really sick or very reclusive, or commit suicide. Sadly, modern research seems to be woefully inadequate in regards to studying the needs, prognosis and mental health of adults on the Autistic Spectrum.