Paediatrics (Part 2/5, RETROSPECTIVE POST)

Paediatrics Outpatients was where I became very enthusiastic for the first time in Clinical Medicine. The awesome thing about Outpatients was that we had the opportunity to see Patients on our own, and then present the information to the Paediatricians afterward for further input. The children always came with at least 1 Parent / Guardian. The majority were for Respiratory or GIT complaints (eg Abdo Pain, Constipation), with some presenting for follow-up following Inpatient management several weeks ago.

To be honest, whilst my Clerking wasn't particularly good at the time as I didn't use any shortcuts and was being too methodical in both History and Physical Exam, and writing all the details down (and thus taking too long), I really enjoyed the Consultations. For some reason I found it quite easy at the time to engage both the the child and the parent, something which a senior Paediatrician said was a challenging aspect of the Specialty. I was hypothesizing that it was because I am overly sensitive, and also get distracted easily, it enabled me to “bounce” back and forth between the 2 individuals with little effort. What also facilitated this was that if I had difficulty figuring out what to say next to a parent, I could reduce the “awkwardness” by focusing on the child, and vice versa. Switching to the child was sometimes useful when the parent was being too chatty (which happened frequently).

The best thing was the children (without trying to sound like a Paedophile), I felt I could relate to a lot of them better than the adults. It felt easy for me to talk to the ones who were verbal. The younger ones (especially Pre-Teens) had more concrete thinking which I could relate to (Frontal Lobe underdevelopment). I found it very endearing when one of them asked how they managed to put the Test Tubes (containing Blood) into the computer I was using (in the Outpatient room) in order to obtain the blood results. My basic explanation was that the Test Tubes were being analyzed by a big machine in a lab somewhere else in the hospital, and that the results are recorded by a computer program, which then sends the data electronically to other computers for view. It reminded me of when I was younger and didn't understand how a Fax Machine worked – I used to think that the same piece of paper that got put into a Fax Machine would physically be transported through the thin telephone wires and pop out, to be printed at the receiving end!!!

I could use simpler English (cognitively easier for me) and shorter sentences when speaking to the children without being seen as patronizing. I relished in the fact that I could ask simple questions without pretense like “What is your favourite colour?”, “How old are you?”, “What do you like to play?”, and get straight answers from the Children without being seen as a “loser”, “dickhead”, or “pervert”. The parents also seem pleased that I was engaging with the children and communicating at the same level. Neurologically, I knew that they were less developed than an Adult NT, so I found them much less threatening on the whole, as I perceived them to be cognitively less able of being manipulative and chronically dishonest. This probably increased my confidence which permeated into my behaviour, seemingly despite my poor medical knowledge. I liked how a lot of the NT Children seemed more inquisitive and disinhibited, before they become fully conditioned into their stereotypical, conformist Adult forms. In short, I felt I had more potential to make a positive difference to the Children.

Paediatrics (Part 1/5, RETROSPECTIVE POST)

Following O&G was CAH (Child and Adolescent Health, ie Paediatrics). Of the 9 weeks, I spent about 6 weeks in total at the Paediatrics Department of my Clinical Hospital, and the 3 other weeks at RCH (Royal Children's Hospital) for lectures and a mini-attachment. Paediatrics was the first Clinical Rotation that I REALLY enjoyed and was enthusiastic about, of which there were multiple factors. I temporarily felt “ALIVE” and “SWITCHED ON” which was a huge contrast to my very low state the previous Semester. Another thing that made this Rotation memorable was that all the supervising Paediatricians knew about my AS and were amused by it given its relevance to Paediatrics. None of them were patronizing or treated me like a child. I didn't experience any repercussions in disclosure and knew in advance that it would be taken well.

The Paediatrics Department of my Clinical Hospital was very small compared to RCH, there were about 18 beds, and about 1/3 of them were for Eating Disorders. Being male and not a Paediatrician involved in their care, I was advised to avoid speaking to patients with Eating Disorders (all teenage girls). Most of the rare and complex cases would've been transferred to RCH, so the remaining Case-Mix at the Peripheral Hospitals (including this one) were very “Bread-and-Butter” - Pneumonia, Bronchiolitis, Gastroenteritis, Dehydration, with a bit of Epilepsy. Because there were so few Inpatient beds, I actually spent more time at the Paediatric ED which although had even fewer beds, but had much higher turnover, and hence more opportunities to practice Clerking and Physical Exams.

Like with Women's Health, we had a PBL (Problem-Based Learning) Tute each week at the Clinical Hospital and opportunities to attend Outpatients, along with morning Ward Rounds (including on the Weekends if we'd like).

PBLs were mostly on “Bread-and-Butter” cases. However there were two Tutes that stuck out in my mind, the first one regarding a fictional 4 year old boy who was being assessed for ASD / Fragile X Syndrome. Somewhere in the text it said that the boy had frequent “Tantrums”, particularly coz he wasn't able to communicate his ideas owing to his Speech Delay. I wasn't happy at the term “Tantrum” being used coz it brought the connotations of being naughty, rebellious, and/or manipulative (in reference to NT children, eg at the supermarket wanting something but not getting it), when he was anything but. 

In the Tute, I said I found the term offensive and misleading and that the more appropriate term for such an ASD child would be a “Meltdown” due to his current neurological deficits being unable to meet his personal needs, leading to massive frustration and vulnerability. And that the approach to his “Meltdown” (Education, Accommodations, minimize Sensory Overloads) would be completely different to that of a “Tantrum”, which we were taught to just “ignore the child until they stop whining, to give them the message that their Tantrum isn't working or acceptable”. I feared that parents would treat ASD children having Meltdowns inappropriately, which would just exacerbate the situation and cause more mental scarring. However the Tutor insisted that it was still a “Tantrum” in the literal sense, and was thus appropriate. This incident was very frustrating and ironic to me, given that ASD people like me supposedly take things more literally (relative Frontal Lobe deficits), and have an impaired ability to comprehend language pragmatics (including subtle connotations), and yet it was the Tutor (NT) who took it literally.

The second memorable Tute was about a Teenage girl who had several psychosocial issues to be addressed in conjunction with Epilepsy management, including Smoking, drinking Alcohol, teenage Sex and possible Depression. IIRC, in the passage regarding her Past History, that she “Tried Sexual Intercourse a few times last year but didn't enjoy it, so hasn't had it since.” This phrase was particularly interesting to me, coz it was only then I realized that sometimes, in order to dislike an activity, you have to give it a try first. I literally told the Tutor that “In order to know that she doesn't like Sex, she has to try it first,” in which he concurred. 

It may sound really obvious to others, but it helped influence my approach in life, that part of personal growth involves getting out of one's comfort zone (or narrow interests / repetitive activities) and experiencing new things temporarily, which would assist with developing one's perspective too instead of relying on preconceived notions or fear. I now see it as collecting more data to analyze. Sometimes there are strangers who I'm interested in speaking to, and whilst I used to be too anxious about approaching them at all, now I'm more forthcoming and curious, thinking it's “It's either I speak to them now, or never and continue to wonder what it's like if I had spoken to them”.

Obstetrics and Gynaecology (RETROSPECTIVE POST)

Women’s Health (or Obstetrics & Gynaecology, ie O&G) was the first Rotation I did after a year of Adult Medicine Rotations. I did it at a Women’s Hospital for 9 weeks. We were attached to a Team and were allocated Outpatient and Birthing Suite Sessions to attend on a weekly basis. The Birthing Suite Sessions included several night shifts, which in combination with Obstetrics tutes the following morning, kinda wrecked me, even with Medication. We also had Case Studies to do and exams to prepare for (of which we were given the pool of ~120 questions IN ADVANCE of which the exam will derive from, in which we had to prepare and memorize the answers in advance), which was frustratingly time consuming.

To partially balance that however, we had O&G Consultants who were very passionate lecturers and captivated the attention of nearly all the students in their Lectures and Tutes. One of them was extremely excited about an oncoming Blood Test, that would diagnose Trisomy 21 (Down Syndrome) in the 1st Trimester with supposedly up to 99% Sensitivity and Specificity, which would mean that the more complicated and dangerous investigations of Amniocentesis and Chorionic Villus Sampling would be abolished.

There were Outpatient Sessions for Gynaecology and Obstetrics (for Antenatal Assessments, ie assessing pregnant women’s health).

Gynaecology Outpatients to be honest felt rather repetitive, the most common medical complaints were Menorrhagia (excessive menstrual bleeding), and Dysmenorrhoea (painful menstrual bleeding). It may have seemed mundane, but I was very impressed by the intervention called “Mirena” (essentially a contraceptive IUD which slowly releases an oestrogen called Levonorgestrol to minimize menstruation), which was prescribed very frequently. Even Catholic Hospitals in Melbourne are now allowed to prescribe this “Mirena” for the above 2 indications, with contraception as a “Bonus Side Effect”!!!

We did have a special tute on performing a Gynaecological / Pelvic Exam, on special “Volunteer Tutors” who let us physically examine them, for the Pap Smear and Bimanual Exam. Being a male who was only allowed to do 2 or 3 Pap Smears at Outpatients in total (with the Registrar who initially inserted the Speculum), I appreciated this opportunity to examine a woman. I made the mistake of asking the Tutor to "Spread her legs", because apparently it had sexual connotations, but she assumed I wasn't being offensive coz she thought that I was an International Student and that English wasn't my first Language. For the Pap Smear I went too high up and accidentally rubbed against her Clitoris, and she was moaning, saying “Oooooooh, that’s too high up, go lower!”. I must say the Labia felt rather “fleshy”, and it was challenging for my left Thumb and Index Finger to part the Labia coz it was kinda “wobbly”. I eventually managed to part it and insert the metal Speculum to keep the vaginal wall dilated before using a flashlight and Speculum to swipe her Cervix.

For the Bimanual Exam, I gloved up again and applied some lube on my fingers and slowly put it in. Her vaginal canal felt moist and after asking her to cough IIRC, I eventually managed to slide 4 fingers in, tightly. I then pushed up to “palpate” the cervix and with my left hand on her abdomen, tried to “palpate” her ovaries for any abnormal masses, of which there were none. I was curious how deep and wide the Vaginal Canal was to accommodate a Penis during Sexual Intercourse. It seemed plausible, albeit with the Vaginal Canal being stretched. Although I read that the Clitoris is the most sensitive part of the Female (sexually), I hypothesized that some of the sexual pleasure would also be from the tight sensation experienced from having an erect Penis pushing against the Vaginal Walls. I also envied how a woman could hypothetically “fake” an Orgasm.

Obstetrics Outpatients was much more interesting IMHO due to the variety. I particularly enjoyed measuring the pregnant women’s fundus length (length of Uterus from top to bottom) at different stages of gestation, measuring blood pressure, and also using the Doppler Ultrasound to try to listen to the Foetus’ heartbeats. Hearing the Foetus’ heartbeats would invariably please the pregnant women. I had many opportunities to palpate the women’s uteruses (sp?), but was always paranoid about causing pain or “hurting the foetus” so I always palpated relatively gently, which actually annoyed the O&G Registrar. Medically, I took note of the medications that may be Teratogenic (damaging to Foetus), and I liked the complexity of managing pregnant women with Epilepsy or Bipolar Disorder given that all Anticonvulsants are Teratogenic to some degree apparently.

With regards to the birthing suite, although I didn’t assist much in the actual baby delivery, I did get to participate by helping to perform routine observations (of vital signs) on the mother, fetching blankets, and trying to maintain a conversation. I particularly liked how by talking to the mother, not only was I “helping the time pass”, but I was also partially distracting her from her discomfort or anxieties, ie “hitting two birds with one stone”.

I’d like to note that whilst I’ve heard numerous anecdotes about the hostility between Midwives / Midwifery Students and Medical Students, it wasn’t apparent at the Hospital I was placed at. The Midwives I’ve spoken to were all helpful to some degree and weren’t bullying, thank goodness.

It was a very eye-opening experience to see a baby delivered right in front of your very eyes, so surreal. For some reason I didn’t feel anxious, more excited, but was able to keep my usual flat affect surprisingly.  I was very curious to see what the baby looked like, and it was almost climatic to see the baby’s head get exposed to the outer environment. The mothers seemed to be quite happy and calm upon seeing their child. I also loved the process of slowly pulling on the umbilical cord and eventually pulling out the Placenta, which felt like "warm meat of a mild silicone-like texture". It was very pleasing to my hands, almost as if I could use it as a "stimming-tool" like a stress-ball (obviously inappropriate).

I always wondered why people have children. I know that some of them do it coz they want more “atmosphere” by creating a family, others coz they want “unconditional love” or want to feel needed due to their low self-esteem, and others coz they have seemingly poor judgment and continue to have babies even though they don’t have the personal or financial resources to do so (especially “bogans”). I was disgusted when I saw very obese women who were pregnant, coz it jeopardizes the foetus’s health, but supposedly who am I to judge?

But for a short moment after the baby was born, my internal prejudices about anybody having children when they “shouldn’t be”, vanished completely. I felt privileged to be able to witness childbirth, and to be able to be a participant in their experience. I thought it was being too NT to see it as a privilege, so I had to ask myself later on why it was so, and more objectively I suppose it’s coz it’s a rare experience for me, to be able to observe something that’s literally a once-in-a-lifetime experience for that individual (baby), the pure novelty. I’m sure that if I was hypothetically an O&G Consultant, the baby deliveries and placenta extractions would eventually become mundane as well.

I have extremely early on, ruled out O&G from the Medical Specialties that I’d consider (if I stay in Medicine) due to lack of academic interest and also fear over Medico-Legal Issues. I was also concerned that this very strong Medico-Legal fear would eventually override the joy of observing childbirth which I personally predicted would wear off with repeated experiences. I’ve also read and heard rumours that with the rising Power and ongoing Lobbying from Midwives to have a greater share in Antenatal care and undertake more “normal” baby deliveries independently (with the ongoing funding problems of Australian Healthcare likely giving them even more leverage), the Obstetrician’s role will progressively be devalued.

However, nevertheless, this Rotation was very eye-opening. I think I would’ve enjoyed it a bit more if it weren’t for the “Shift-work” from the Birthing Suite Sessions and the horde of O&G questions I had to prepare for, although I should be grateful in that it’s supposedly better than not knowing the questions in advance, at all.

Graduated

I managed to pass my Final Year Exam (OSCEs) and graduated on December 14th, 2013.

In the Graduation Ceremony, when my name got called out, I collected my Testamurs (MBBS, BMedSci) which was followed by a huge applause and cheering from the audience (especially my classmates). All along I thought I was lonely, but at the end of the day, they apparently seemed to have an inkling about what I was going through.

7 years of University Study, over.

 It's difficult for me to articulate how relieved I am that I've gone this far and attained the Medical Degree. There were so many ups and downs, and whilst some Patients I found very annoying, I've also met Patients who were encouraging, and Doctors who were supportive and inspired me, as a few of them also had their trials and tribulations. The course was gruelling, and there have been times where I regretted studying Medicine, but given my personal circumstances (particularly my discovery of my AS), it's given the Medical Course even more value, even if I don't work as a Doctor in the future.

I know that there'll be many more hurdles ahead in the future. It's a matter of whether I can handle it or not, and whether the Fight is worth it.

I've been very burnt out and have decided to take a Gap Year to recuperate. I'm a Local Student, so apparently I'm still guaranteed an Internship for 2015 in Victoria, although things are starting to get tight given the local graduate oversupply. I'm supposed to feel extremely happy about graduating, but I also feel very empty inside, coz I'm not proceeding straight to Internship like everyone else.

I suspect a lot of this emptiness is that now my temporary battle in Medicine is over (for now), I have so much temporary freedom that I don't know what to do with it. The uncertainty over my future, and also the lack of guidance. Med School took over so much of my life, at the expense of my "Personal Life", Special Interests, and this Blog. I guess I should get back to rekindling some of my Special Interests, and possibly exploring new ones, along with learning other new skills, so I can have a greater "Armamentarium / Repository" of coping strategies to help reduce Burnout during the actual Internship. Oh and along with typing all those Blog Posts that I wanted to do, but never got to doing.

In retrospect, I could've gained even more from Med School if I had known back in 1st Year, what I know now, but that can't be changed. I just have to reflect on the past, and try to move forwards. Every day that passes, is one day closer to my Death. This Gap Year is my Saving Grace, for me to rest and sort through as many issues as possible.

I better get going for now.

Happy New Year to everyone!!!!!!

Quotes in Med School

Medicine is taking over my life... I'm so damn behind in both my studies and blog entries and in some respects I'm frustrated with myself. The Medical Conditions are interesting in their own right, but I got a backlog to catch up on which reduces the fun due to the added pressure of going through a sheer volume.

In the meantime, here are some quotes that I've collected so far in Clinical Rotations. Enjoy...

From Consultants:

“When you get married, the expenses go up a lot more…See the trick is that they’re working when you meet them for the first time, but after you marry them and have children, they quit their job and you have to support them and the children - school fees, cars, holiday trips etc.”

“When people apply to us for a Trainee Position, we can already tell which people we’re going to accept.”

“You think you’re busy as a Medical Student? Wait til you become a Consultant.”

“We try to avoid Mediterranean patients as much as possible, they come in with all of these physical complaints and we usually don’t find anything… it’s usually their way of somatizing a mood condition such as depression or anxiety.”

“Didn’t you know it’s a birthright in Australia? “If anything wrong happens to me it’s your fault.” ”

“3 years will go by like a blip.”

“I think you’re in the wrong career.” (when I said I wanted to do a specialty that had office hours, Monday – Friday with no on-call.)

“You need to get a hobby, because Medicine will take over your whole life.” (to our tute group)

“That’s to teach you a lesson, that you chose the wrong career.” (when I said that we only had ~4 weeks of Summer Holidays.)

“I am bitter and jaded, there are all these obese patients and they don’t put in the effort to lose weight through diet or exercise even though we try to help them do so.”

“99% of patients are fat coz they have shit diets.”

“They don’t want to fail you, the government has already invested so much money into your education.”

“When you choose a Specialty to train in, you really need to consider if you’re happy dealing with the bread-and-butter conditions for 20+ years coz that is what you’re mostly going to deal with…There are a lot of burnt out consultants in their 40’s and 50’s because they see the same condition over and over again and it gets to the point where it feels monotonous.”

“Yeah he (another Consultant) lives at this hospital, it’s like his second home.”

“Yes that’s me in the photo, when I was young and free…”

“You need to know what conditions to look for before you start taking a history and doing a physical examination.”

“Don’t always believe what other people say about a patient. There will be times where you are right and everybody else is wrong, so you need to know how to do the history taking and physical exam yourself.”

“Medical Scientists can’t get sued, so if something goes wrong in the lab, they’ll try to go after the Pathologist.”

“The future of Medicine in Australia will be very different…you will be doing a lot of handovers due to 8-hr shifts due to the Medical Graduate Tsunami…you will be practicing conservative Medicine where you order less tests/investigations unless they’re very necessary.”

“There are a lot of Asian Med Students who are studying Medicine due to parental pressure…if they’re only in it coz of their parents, it’s going to fuck them up later on in life.”

“You need to be genuinely interested about a Medical Specialty…there are a lot of specialists out there who are not dumb but still managed to complete the training program, but their lack of enthusiasm manifests through multiple things that we politely call “hindrances” within the hospital system.”

“When you’re stressed, it’s hard to recall Mnemonics! Try to learn things conceptually instead.”

From Registrars:

“As a Med Student, you have the most opportunities to practice physical exams and search for interesting findings on patients, coz when you do Internship, you’ll be too busy with paperwork to have any time.”

“I just don’t feel happy. I work extra shifts so I can feel useful…”

“When you work in the ED, patients with Borderline Personality Disorder will be your bane.”

“Why does everyone talk about that? … Oh we just enjoy our work, the money you get in Internship will be much more than what you receive as a student on Youth Allowance… My friend works at Kraft and she gets paid a monthly salary… They should make doctors earn a monthly salary instead so they have to do all of the hours they need to do without complaining.” (in response to my mention of unrostered overtime.)

  

“If you don’t want to work your ass off, be a GP.”

From Nurses:

“Nurses are the ones that do most of the work.”

“The Hospital can’t run without us.”

“I often feel that in Palliative Care, people take things too far and give patients unnecessary interventions that just prolong their suffering even though they’re dying… Their family just wants everything done coz they know the staff will do it for them for free.”

“There will always be a proportion of doctors and nurses that have substance abuse issues, so you have to be mindful of that.”

“When I started smoking as a nursing student long ago, it was a common thing for us to do and a ritual. During our breaks we’d sit around a table and light our cigarettes together…I don’t really know if I actually got addicted to the nicotine given that I’m a light smoker, but you get addicted to the action itself.”

“If a patient is being aggressive to you, the trick is to try and look calm.”

“All of the Spinal (canal stenosis) patients smoke weed. We sometimes have them get admitted to ED due to being too stoned.”

“If you learn the information, the work becomes more stimulating because you can tell the subtle differences.”  

From patients:

“The thing is to try to find people who share similar interests to you.”

 

“The notion of Medicare has completely distorted people’s perceptions about the level of healthcare they can receive for free…they expect and want everything for free without realizing the true cost of the services, tests and treatments provided.”

“You can tell who your real friends are by how they respond when you ask if they’re actually coming to visit you when you’re sick in the hospital.”

From other people:

“Don’t lose that curiosity!”