Barriers and Professionalism?

I can see the light at the end of the tunnel! To be honest though the placement went by a lot faster than I thought. I can't really complain about the length of it as I'm only in 3 days/week. Obviously knowing that the placement is coming to an end and going back home for holiday is getting near - my mood has definitely been a lot better. Plus the weather is an added bonus. Finally summer is here...hopefully it'll last for more than 1 week.

Had a pretty straight forward short week (in for 2.5 days). Not much really happened, but I was placed with GPs who were more keen to get me involved and doing stuff, which was good. Did ONE (wowwww) consultation on an "unwell" child who was more miserable than anything. It was a fairly straight forward case as the child had a general viral illness and just needed a lot of TLC. I did get to go out with a district nurse which was good as it got me out from the practice. Visited 5 patients and went to their homes. Personally I still find it a bit uncomfortable to be in other peoples' homes. Maybe it's the way I was brought up or culture difference, but I feel very intrusive when going to someone's home and sitting down and making myself comfortable.

The nurse took me to an elderly couple's home who she knew quite well as she visits them almost every week for monitoring. The couple were immigrants and seemed to be quite private and quiet. Obviously noticing that when first meeting them, I instantly felt a bit hesitant entering their home as a complete stranger and at the end of the day - I am just a medical student. Seeing how they are, I obviously waited for them to ask me to sit down before making myself comfortable, but what really surprised me was the nurse's behaviour. I guess since she has known them much longer, she didn't feel the need to be more professional. As I sat down, the nurse was already walking towards the kitchen and asking at the same time to turn on the kettle to make herself a cup of coffee. It was obvious that it was rhetorical question as she was already halfway to the kitchen. She did also ask me if I wanted tea/coffee but I politely refused. I was very confused by this as the nurse was happily making herself at home, using the couple's kitchen and coffee/tea supplies, etc. I personally found it a bit rude, but then again I don't know how well she knows the couple. I would never use a patient's facilities and no matter how well I know them, I would never make myself comfortable in their home. I feel like it's just a professionalism thing more than anything else. At the end of the day, they are my patients and I need to treat them as patients to maintain the professional doctor-patient relationship...or in this case nurse-patient relationship. I guess in general nurses are a lot better with maintaining good relationships with patients and come across much more empathetic and kind. Not only did I feel very uncomfortable in the patient's home, the nurse was taking her sweet time to make herself comfortable and making her coffee, leaving me alone with the couple. It was nice talking to them, but at the end of the day - we were there to go over their blood-sugar diaries and just seeing how they are doing. What could be done very quickly...ended up being a fairly long ordeal (about 30-45 minutes). I don't like to make things take longer than they do. I do understand these are house-bound couples, but I feel like by taking so long to do a job may be interrupting their day. As an outsider - I want to make my visit as quick as possible so they can return to their activities. So again the whole making yourself comfortable in someone else's home was puzzling. Even better, the nurse went to use the couple's bathroom...which again made me raise an eyebrow. If I needed to use the toilet, I would've went before the visit, or hold it and go somewhere else to use the facilities.

If we flipped it around and a nurse/worker or whatever had to come to my home once a week to do some checks...I personally wouldn't want this person to make themselves comfortable in my home. Maybe I'm just a private person or how I have been brought up. I don't mind friends/people who I know well to come over and make themselves at home, but when professionals/workers come...I wouldn't be as comfortable with them making themselves at home. I see them as someone who is here to do a job - not to socialize and I wouldn't expect/want them to break down that barrier of professionalism.

Just found it a bit interesting and wanted to share that experience.

Old Age.

Had quite a weird week...weird as in a week which really made me change my perspective on things.

I got to go visit a nursing home for people with dementia. I had previously volunteered in a nursing home before medical school but I didn't work with patients with dementia. I went to visit a 75 year old man who has vascular dementia and had just moved to this new home. The nursing staff were worried about him as he had spent the entire night pacing up and down the hallways continuously for 15 hours non-stop. I went into his room and sat down in front of him. His room was fairly small. One single bed. One small wardrobe in the corner. 1 night stand. 1 cabinet. This man just sat in his chair, hunched over. He wore a baseball cap so I couldn't see his face. As he sat there I saw him dribbling on to the floor. It was almost like he wasn't even there and was staring at his shadow. I looked over to his night stand and saw 2 pictures of him and his family. In the pictures, he was middle-aged and appeared to be a very proud man. He stood in the pictures full of confidence. He looked very happy. Then I looked back at the patient, still dribbling and staring at the ground. He looked quite frail. I eventually said hello to him and he didn't reply. I moved his hat a bit so I could see his face. He still stared at the ground. I asked him what is his name and he replied me without looking up. I tried to carry out a very basic conversation with him, which proved difficult as midway through he started mumbling. I couldn't quite understand him and he quickly stood up. He walked to his wardrobe and was very unsteady on his feet. He had a very unbalanced waddling gait. I asked him where is he going and he replied: "Home". I kindly told him this is his home and to sit down again. As he came back to his seat I looked into his eyes and he didn't look happy. He didn't really even look like the man in the picture by his bed. As he sat down, he went back to staring at the ground and stopped talking to me. I just sat there looking at him. I thought to myself: Is this how residents here pass their day? I found it pretty sad as they just sit in a fairly tiny room. This particular man, if he isn't pacing up and down the hallway, he is sat in his chair almost lifeless. Really made me think that people need to live their life to the fullest. Appreciate the things and people around them. I felt bad for this man. His life seemed pointless. He was confused. Ageing is a scary thing. Just comparing this man to the man in the pictures - it is almost like night and day.

Then when I went back to the GP practice, I met another lady who desperately needed a total hip replacement. Her x-rays showed severe osteoarthritis (OA) as in it was bone on bone. The patient had a shortened right leg as well due to the OA. On palpation of the greater trochanter...it felt like you were running your hand over a bag of marbles. You could feel the osteophytes! Range of movement was severely decreased and the patient had pain on extension and flexion. Actually any movement made the patient jump. It was fairly remarkable that she doesn't need to use any aids to walk, but you can tell she is struggling. Unfortunately, the surgeons do not want to operate on her due to her health and as well she does not have anyone at home to look after her. She told me that she has outlived her entire family and there was no one left. She explained to me that she tries her best to get through the day, but usually just stays at home to avoid any hassle and because her hip hurts too much. She has tried all sorts of analgesics and even tried topical treatments (which doesn't work, which is no surprise as her hip was bone on bone). I asked her what does she do every day if she doesn't really go out. She told me she just sits there and read and told me that her life has become very boring and that there isn't much meaning to it any more. She talked about how active she was when she was young and gradually as her hip got worse, she couldn't go out for walks in the park or even do her gardening.

If you think about it, when I start reaching the peak of my career, the majority of my patients will be the elderly. In general the population would be quite old as the current generation of "baby boomers" are starting to reach retirement age. I think it is key for medical students to learn how to deal with the elderly. It is frustrating to hear students go: "I don't like old people. I hate talking to them." I sometimes can't help but say back to them: "Well start liking it as the population ain't getting any younger." I'm sure I have said this before,  but I quite enjoy talking to the elderly. They always have a great story to tell or have some pretty wise things to say to you. They are all so strong as they have been through so much. They seriously need a heck load more respect from people of my generation and the younger generations. Ageing is the fact of life and there isn't any way to avoid it (well unless something really tragic happens to you at a young age...). Sometimes it is just hard to see what the future lies for you when you see so many elderly patients.

Walls Closing In.

Yes this is another s*** hitting the fan post.

1 report on screening programs.
1 audit report.
1 audit poster.
1 audit abstract.

The beauty of finding out that instead of having 2 full three-day weekends to work on all these things....you actually have 3 full free days to work.

16 days left until deadline.

Calling for lots of coffee. A lot of creative power. And very little sleep. I refuse to let GP be the one placement that becomes the hurdle of my medical degree.

I knew I was going to regret bumming around. Grrrr.

Help!

Just Need to Ask.

As you have all realized, I am not enjoying my GP placement as I haven't really gotten to do anything hands-on. Learning is minimal and I essentially just sit the day away. Last week, I requested to sit in with a GP who has a special interest in MSK. Finally got a schedule I could smile about. I was placed in a surgery where majority of the patients came in with MSK complaints. Then my next day was placed in the hospital (oh how much I miss the hospital environment) to shadow a physiotherapist.

Because I am so sick of sitting around, I finally opened my mouth and asked if I could do joint examinations.  The GP was more than happy to allow me to examine and started introducing me as the "Student doctor with a special interest in muscles and bones." Clinic for once actually went by quickly and was fairly enjoyable. Then I decided to ask the physio on my next day if I could participate and get involved. She was also more than happy to allow me. The physio had a special interest in upper limbs while I am interested in lower limbs. It was good for me as I am obviously missing quite a bit of knowledge about upper limbs. I learned loads about the common injuries and presentations you see in upper limbs. I also got to work on my upper limb examination skills which involved a bit of neuro; therefore, it was a really good refresher.  It was also fun to talk to someone who knows the orthopaedic consultants in the hospital and just learn more about the other sub-specialties in orthopaedics.  I got to know about the spinal unit and the shoulder consultants and what they would usually see.

It was also cool to see what would count as an urgent referral as we had one patient who we believe to have cauda equina syndrome. Cauda Equina is essentially where your spinal cord goes further down your spinal column than most people. Most people's spinal cord terminate at L1/L2; therefore, when you do a lumbar puncture, you make sure you go below that to avoid the risk of paralysis. The patient presented with urinary retention symptoms and decreased anal tone.  He also complained of changed sensation in his genitalia region.  It was evident that he also had bi-lateral leg weakness. His symptoms fit cauda equina syndrome so we had to urgently refer him to get an MRI scan. It was also interesting because the patient was claustrophobic and he made it very clear he does not want an MRI scan. We told him that the hospital has a wider scanner so it won't be as tight, but the patient was still adamant that he doesn't want to go through a closed scanner. He allowed us to refer, but he told us that he will refuse to go in on the day. We told him there is medication that he can take before he goes in to keep him calm that he can get from his GP. I don't know why but I felt like he is still adamant that he isn't going to get the scan done and will not go get the medication from his GP. Cauda Equina Syndrome can be quite serious and need to be treated so it was a bit frustrating to see someone refusing a simple scan which can rule out cauda equina.

Then I got a bit of a reality check near the end of physio clinic. I have suffered from a shoulder injury for 5 years now, and never really bothered to take myself to see a doctor. It's a thing about medics: "Medics either go see a doctor too early, or go too late." In my case: I just never go. A shoulder patient came in who obviously needs a shoulder replacement due to OA in the shoulder. The patient had very limited range of movement and you could hear his shoulder grinding as he was abducting his arm. He explained to us that it has completely hindered his lifestyle as he can't even reach up to get things from the cupboard and it is quite painful. He then mentioned that when he was young (my age) he had a few shoulder injuries and reckons that due to those injuries - he now has pretty bad OA of his shoulder. Once the patient left, I told the physio about my shoulder and she sternly told me to go see a GP and get a referral to either physio or orthopaedics as  I am susceptible to early OA if I don't get it sorted out. Even worse, it could hinder my ability to do orthopaedics in the future as it requires a lot of strength and lifting.

To be honest, the physio is right. I've left my shoulder long enough and it is obviously not getting better. Hate being on the other side of the table as the patient.

A Mask.

This isn't a new revelation, but one that has occurred to me more during my GP placement.

I have come to realize that doctors need to put on a mask most of the time as patients come to doctors for various kinds of problems. No matter how annoyed you are about a patient or how fed up you are with your clinic, you cannot let it show. There are tons of patients out there who visit the GP 2-4x a month and I'm sure as the GP you can get frustrated/annoyed with the patient especially when they are coming in for insignificant things.  It is definitely difficult as patients expect the doctor to be professional and empathetic, but it is extremely difficult to show this when the patient themselves aren't coming in with the right intentions. I have sat in clinics where the patient is very rude and overly demanding. And as a doctor, you can't do anything about their rudeness, other than still treat them respectfully and try your best to listen. Definitely need a high tolerance level when dealing with "troublesome" patients. On the contrary, there are certainly very nice patients (usually tend to be the elderly). They are usually very respectful and always apologizing about wasting your time. These are the patients who are worth treating and you can't help but be a bit more empathetic, despite knowing that you're supposed to treat all patients with empathy and care.

However, masks are not just for GPs. As I have mentioned earlier, I have encountered it in my other placements. You would think surgeons wouldn't need to put on a mask as often, as they have a bit less patient contact. Unfortunately, surgeons have just as much face time with patients; however, the reasons of putting on a mask may be different. After a surgery and you have to break some bad news/complications about the surgery, you have to be able to put on a confident face and an appropriate mask. There isn't as much time for you to gather yourself after the operation. GPs or physicians in general would get results/bad news ahead of time so they will be ready and have time to think about how they will break the news. It is definitely a tough job as you don't want to show that much emotion when talking to patients especially after a tough case/surgery.

With clinics, you could enjoy the company of one of the patients and be laughing about something, but you have to be able to quickly return back to neutral before seeing your next patient. It can work the other way around as for one particular case, we were giving our condolences to a patient as her father had just passed away the day before and she was telling us about his death. Definitely an emotional/sad moment where you have to again put on a mask and empathize and comfort the patient. Easily within 2 minutes between patients, you have to regain your composure and be ready for the next patient as he or she can come in with anything. You certainly can't let things affect you and as well for doctors, you have to be good with moving on. You can't dwell on one particular case.

There has been arguments that doctors should not bring their outside emotions to work. Despite having a horrible morning, people argue that you shouldn't bring that grumpiness into the work place. I personally agree with that point as it isn't fair to your patients and your colleagues. I have met a few GPs who said that it is important to bring your emotions to work as you will seem more genuine. I don't mind bringing in a good mood to work, but I certainly wouldn't want to bring in grumpiness to the work place as you can easily affect your patients and colleagues. No one wants to see a grumpy doctor. In my eyes, I think my emotions should not affect my work, so even in that sense, you will have to put on a mask before coming to work especially when you're having a bad day. People argue as a doctor you should be genuine, but for me it is far more advantageous if I put on a mask for work and sort out my issues/problems when I go home/leave work.

What are your thoughts about putting on a mask for work or bringing your emotions to work?

Post your comments below!

Unreasonable.

One of my biggest pet peeves is when someone wrecks my lunch breaks for no reason. I don't mind missing my lunch because I am in theatre or doing something productive. Actually I don't mind if I'm in clinic and I have to delay my lunch...but what really drives me mental is when someone makes me MISS my lunch when it really didn't need to be missed.

I don't know if I am just being unreasonable or uncooperative, but essentially here's the story:

One week ago I gave notice that I have to attend a compulsory observation session at a clinic which is quite far away. I asked the secretary who does up my schedules if it will be possible for me to leave slightly earlier so I have some travel time and a time for me to eat my lunch. I was told by the secretary that it will be okay and she has left a note for the GP who I will be following in the morning.

Fast forward to today. I made sure I arrived early and kindly asked the GP if I could leave at 11am so I could go to my session at 12:30pm. Clinic usually ends at 11:30am so it wasn't like I'm asking to get off 2 hours early. It was simply just leaving 30 minutes early which is equivalent to seeing 2-3 patients. Despite seeing the note left for the GP about me leaving early, I was then given a fairly rude look and essentially was told why I can't leave after clinic (11:30am ish). Still maintaining my composure, I told the GP that I need to go home and drop off my car and then make my way to the other clinic (which has no parking hence I need to take the bus), and that I would like to have a bit of time to have some lunch as well. The drive home probably takes about 20-30 minutes depending on traffic, then another 30 minutes to travel to the other clinic. That would leave me about 30 minutes lunch break...which isn't unreasonably long. I explained this to the GP and she essentially didn't even listen and proceeded to interrupt me. She went on how I can leave at 11:30am and have my lunch on the go while traveling to the other clinic. I was obviously fuming as I do not understand what is the importance of me staying for an extra 30 minutes. Either way I just sit there and day dream as I don't do anything in clinic. I just sit and listen...and try to stay awake. I think the most annoying bit was the rude attitude the GP gave me first thing when I asked to leave early almost giving me the vibe that she's the "know it all - who are you to leave early" attitude. Hate it when people get all arrogant like that. I asked for permission a week in advance and again I'm only leaving 30 minutes early.

What also drove me mental was in the last 30 minutes of clinic....one patient needed a sick note/letter and another patient needed a wound to be checked for possible infection. Wow...that was surely useful....I couldn't help but give the GP a look of: "You seriously kept me an extra 30 minutes to see these things?!" Once the clinic was done all you could see behind me was a cloud of dust. Raced home and raced back out to clinic. No lunch. No snack. Didn't even have time to drop off my car keys. By the time I got to the other clinic...I felt like I was going to faint. I was starving and I had a smaller breakfast than usual as I thought I would be having an earlier lunch.

I mean I think the GP was being highly unreasonable and very inflexible especially when I had a valid reason and a reason which was something the medical school required me to attend. I wouldn't even care if I had to miss my lunch because an operation overran and we had to skip lunch so we will stay on time plus the consultant starves with you. I swear this GP did not help me with my experience with this placement so far. To most, if not all of you, you probably think this is such a small thing...why the heck is it bothering me so much. My tolerance for this placement is getting very thin and I am starting to really lose motivation in even putting in effort.

New Template.

Well I got a bit bored and pretty much re-vamped my blog. If you don't like this template or have any suggestions in terms of colour/font/etc, just leave a comment below. Hopefully you'll like this template more as it is a bit brighter and probably a bit easier on the eyes when reading.