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.

O&G Ward Week.

You can hardly call this my "Ward Week" as I probably spent more time in clinics than on the ward. This week also marks my last timetabled week of my placement and I have been seriously trying my best to enjoy every day of it as there is a bit more flexibility with my week.

Spent Monday morning in Gynae clinic. I managed to see a lot of prolapses such as cystoceles (proplapse of the bladder). Luckily the consultant has gotten to know me as I've been in a few of his clinics with him so I got to do a vaginal examination on almost every patient. It was interesting to feel a prolapse as it is definitely very different and then feel the difference when a shelf/pessary is inserted as a temporary treatment for the prolapse. Patients with cystoceles tend to classically present with a "dragging" feeling down below which becomes quite uncomfortable as the day progresses. There is also a "heavy" feeling, which again gets worse as the day progresses especially when stood up for a long time. Some of these patients also present with urinary symptoms such as urinary frequency and hesitancy. I think by coincidence these patients also present with some form of urinary incontinence as well. Usually elderly women would not be offered a surgical repair where stitches will be placed to reinforce the anterior wall of the vagina (where the bladder prolapses through) as these patients are usually unsuitable to go under anaesthesia.  By the looks of it, most of the women are fine with the pessary and it seems to sort out their problems quite well.

Then I wandered onto the wards with one main goal in my mind: Take as many gynae patient histories as possible. Why so keen? This is because my assessment is taking place the following day. Essentially we are required to take a full patient history with an assessor sitting alongside. This assessment either makes or breaks me. If I fail, I would obviously have to resit the assessment which would go down on my records that I had 1 failed attempt. If I fail the second time, then I will have to repeat the entire 7 week placement all over again. I mean I'm having a good time on this placement, but if you asked me to do another 7 weeks, it might be a bit of an overkill. Anyways I took about 4 patient histories in the afternoon and had a good time talking to patients. It's nice to see patients enjoying talking to me as I guess for them it is better than sitting in silence and day dreaming as the hospital is pretty boring in general.

So I had my assessment...and oddly enough...I wasn't too nervous for it. Actually I was so calm it was worrying. I was struggling to take the assessment seriously as before I went in to take the patient history I was chatting away with my colleagues (well I did the talking...they just listened as they all looked very nervous). I kept telling myself to take this assessment seriously but I struggled. I was fairly annoyed with myself, but at the same time - if I'm in a good mood I tend to take better patient histories and form much better rapport with the patients, which is key for the assessment. Luckily, my patient wasn't too complicated (vaginal hysterectomy and anterior wall repair). I finished my history quite quickly and  I thought I did quite well. Didn't have any difficulties whatsoever. Huge contrast from my last placement (paediatrics) assessment. In my last placement I was properly pooping myself prior to my assessment and I was dead scared. I was much more confident for this gynae assessment - night and day in terms of confidence between my last placement assessment and this one. My assessor had no difficulties in passing me and even gave me an "above average" mark which I was quite chuffed about. I was quite proud of myself as I was only expecting a "meets expectation" as my supervisor is known to be quite strict with marking.

Since my next assessment isn't until next week, I knew I can relax for a bit and return to enjoying my placement. Oddly enough I thought I was going to be quite bored on the wards as there isn't much a medical student can do on the wards, but I was actually quite productive on the wards. The doctors were all really welcoming and actually allowed me to write in the medical notes and sign off on them (of course the doctors reviewed and counter-signed my notes). I also got to clerk in a few patients, which is always interesting. It's weird seeing how seriously some of the patients treat me. I mean at the end of the day I'm just a medical student, but these patients really take everything I say seriously and show a lot of respect. It's quite nice to not be treated as a joke and it definitely makes me feel much more responsible.

Because my next assessment is on obstetrics and I haven't had much exposure to it on the wards, I decided to spend my day on the obstetrics ward and practice my obstetrics examination skills. And jeez....I suck at obstetrics examination. I swear I cannot feel a thing. In our assessment I'm supposed to be able to tell the position of the baby, the engagement of the head, the lie, etc. I feel like my hands are dead stubborn as I swear the bum of the baby feels the same as the head! Yes I know one side is flat and the other is round like a ball, but at the same time I'm too scared to palpate deeply in fear of hurting the mother. I definitely need to get more confident in doing this examination or else I will fail my final assessment. Not looking good. I thought I could get away with just a full day of practice, but I definitely need to go back to the obstetrics ward next week to examine more pregnant women. I think I did leave a good impression with the midwives as they seemed keen to have me around and that I am welcomed to come back next week to practice some more.

1 more week until holiday...well not even. Technically only 2.5 more days of placement left as I have a half day next Thursday (and Monday is a bank holiday and I get Friday off).  Can't believe it's already been 7 weeks. I can still remember my very first lecture for O&G like it was just yesterday. This placement seriously went by way too fast...and I'm having such a good time. Argh.

The Key is to be Proactive

Have been in placements for about 10 weeks now and I have had many ups and downs as you have read in my previous posts. After looking back at my placements, I've realized that my best experiences had been when I am being proactive. Being active in learning and stepping out from my consultant's shadow. In my first placement in the summer, I put a lot of effort into taking patient histories and doing loads of physical examinations (cardio, resp, and abdo). 2nd placement...did a lot of ward rounds - definitely seen a lot. For comparison sake - first placement I took about 10 patient histories and have done 4 cardiac exams, 3 respiratory exams, and 3 abdo exams. 2nd placement: 1 patient history, 1 shortened peripheral nerve exam. Poor showing in the 2nd placement. Yesterday, I did a group revision session on cardiac, resp, and abdo examinations. I knew how to do those examinations quite well and knew what I was looking for and can easily explain positive findings. The minute we got into neuro and musculoskeletal (MSK) exams...I died a little inside. I didn't know what was going on. Okay well MSK was easy to follow as I'm quite familiar with joints and those tests...but neuro was painful. I obviously didn't know how to do these exams as well as the cardio, resp, and abdo exams and it just felt horrible how lopsided my learning has been. Thinking back - it was because I was really proactive in my first placement. I had put a lot of effort into seeing patients and doing examinations. These last 2 placements - I've been...how should we put it...lazy.

You might ask: why suddenly the realization? Yesterday I was in clinic in the afternoon and my consultant told me to go take patient histories of the new patients in clinic and to come back and present the histories to him. While presenting, my consultant would ask questions dealing with the presenting complaint and about the differential diagnosis. It really made me think and be on the ball. When I didn't know something - he would teach me what to look for in a history and I realized: "I'm actually learning and remembering this." Once clinic was over - I actually had a good time. I felt independent and a lot more confident in my history taking skills as I got to present my histories and then got quizzed on it. I also realized that I was quite rough with my history taking with my first patient but by the time I saw my 3rd patient - it was easy and straight forward. It was a great feeling and a great confidence boost.

Now I'm sitting about - pondering - actually no...stressing about exams (OSCE + 2 written papers in December). There's no way I can pull off taking good histories and performing examinations without practice. I need to be proactive and do what I did in my first placement. Make a schedule and follow it. Be involved and just take a step away from my consultant and tell him that I need to practice. There isn't much point following him - I've got a good idea what the specialty is about already. I need to see more physical signs and conditions to start seeing patterns and recognizing things quicker. 4 more weeks of placements - I need to get back on the wards and talk to patients!

End of the Week.

What a week.

Driving to the peripheral hospital for 40 minutes each way every day does take a toll. Since Monday, I have been going in at about 9 or 10 am, which is considered a late start when compared to others. My consultant is fairly "slack" and told us not to come in too early because we do have to travel a long way and for safety sake not to tire us out too badly. Last few days my partner and I have been going around to different wards to take patient histories and do physical examinations. I swear we have not been that lucky this week. We have been given two patients on our ward who we should definitely speak to as they are quite interesting to talk to and one patient in particular is extremely fun to talk to. Every time we wanted to go speak to this one patient, he is asleep in his chair. We were told by the nurses and junior doctors to not wake him up as he gets tired quite easily (plus he is quite old). Finally, when my partner and I walked by his room he was awake so we went in to ask for permission to speak to him about his condition.

I am not kidding but I think the entire ward (nurses and junior doctors) were playing a mighty good prank on us. Here's the catch: this patient is almost completely deaf. We literally spoke right into his ear and he still could not hear us. My partner and I were absolutely baffled. We could not believe that the staff had been recommending us a patient who is deaf. The main point of patient histories is to ask questions and it does not exactly work if the patient cannot hear you. Now we feel like we are the joke of the ward. However I am VERY determined to get a patient history from this patient as I had a read through his notes and he is definitely an interesting patient. I think I will opt for the writing on a whiteboard to ask my questions.

After being absolutely baffled by this patient, my partner and I decided to abandon our ward and move to other wards to get patient histories. We went to the Cardiology ward and we managed to get a really good patient history. This particular patient was very kind and VERY patient with us. We visited him again today to do a Cardiovascular physical examination on him and again he was very cooperative and seemed really keen on helping us learn.

Today we also went to the respiratory ward and managed to get another patient history and do a respiratory physical examination. Despite being a Friday, I thought today was one of our most productive days. Last few days we were leaving early (e.g. 1:30pm-2:00pm) as we felt redundant. Today, we left feeling like we've done a lot and actually had some fun. Definitely a good way to end the week of placements.

Next week - hopefully we'll start off where we left off and continue to be productive. On Monday we will be doing a theatre list with our consultant so we'll finally see him again and hopefully get some teaching from him as well as he is amazing at teaching and very patient. I was also hoping to ask to be able to scrub in and maybe be a bit more interactive and try and help out as I think that is the best way to learn. Much better than standing in the corner of the room and trying not to be in the way.

Sorry for the long post. Will update hopefully soon. Have a good weekend!