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.

Obs&Gynae - Initial Thoughts

So I have completed my first week of placement for Obstetrics and Gynaecology. Initial impressions? Fairly interesting. It's nice to see adult patients again. When I took my first patient history on this attachment, it was weird being able to speak directly to the patient and receiving specific information. Also in Obstetrics (pregnant women), you can't really call these people 'patients' as most of them are healthy and essentially are only in hospital to give birth. It's quite a nice change of environment from seeing ill children. In Gynaecology, one has to be quite professional as this specialty deals with quite sensitive things. You have to ask personal questions and you really need to gain the trust of your patients in order to get such personal/sensitive information.  Again a huge contrast from Paediatrics as I have to put on a "fun" attitude when approaching children; however, with gynaecological patients, I have to be composed and essentially act professionally. It is a nice change and I haven't found the transition too difficult...yet. We'll see in the next few weeks.

Again I am in a peripheral hospital, but this hospital isn't actually that far away. For me, it is actually closer than the central hospital so I'm not complaining. It's great to be in a hospital which has a good reputation for teaching. They pride themselves in teaching and on day 1 it was very noticeable. The supervisor and secretary was very organized and were expecting us. We felt very welcomed and we received our schedule for the next 6 weeks! I was not expecting a schedule as in my previous attachment everything was done ad hoc and we received little guidance. Huge difference for this attachment and it was definitely a change I welcomed. It was nice knowing what you will be doing in the next few weeks and I could actually plan my life as I will know when I will be free and I can prepare ahead of time for clinics/teaching.

On top of that, I have come to realize how patient some people are. I went onto the wards to help out and was given the task of clerking in 2 new patients. These 2 patients have not seen anyone yet, so I was excited to go talk to them. The first patient I saw was having severe pain and to my surprise, she had been waiting to be seen for 4.5 hours! Talk about patience! I would've left ages ago and I found it quite ridiculous someone in so much pain has been waiting for so long! After taking the patient history, I realized this patient was in a lot of pain and a doctor had to see her soon. In addition to that, the patient was not impressed with the care so far (not surprised) so I quickly went to go get a senior doctor. It was found that she had surgery a week ago and the stitches were infected and some of it has come away. This patient was promptly admitted to the ward and was finally given stronger pain killers and a surgeon was called to review the case.

Then I went to go talk to my next patient...who actually arrived earlier than the last patient I saw. She had been waiting for 5 hours and I felt really bad for her. She had come to A+E the day before and due to the long wait she left and decided to come to the ward the next day. Because the ward was fairly busy, no one has really seen her and again I was the first person to see her. This could of easily been the longest history I had ever taken. After introducing myself I asked the standard question: "What brings you to hospital today?". This patient went on and on with a very extensive history of her presenting complaint and I was overwhelmed with information. She did not stop talking for a good 10-15 minutes and I was completely lost. I slowly had to work my way back through her history to get a more clear idea what was wrong and this clerking felt like it took ages. It didn't help that this lady's first language was not English so I had to word my questions differently and I had to try and figure out some of her medical conditions as she didn't know the names. It was the few times I actually struggled taking a patient history and this is the first time where there was a bit of a language barrier between the patient and I. It was a good challenge and it was new experience. It definitely taught me to be patient and to take things one by one. Luckily the patient was patient with me as we worked our way through the problem and her history and after 40 minutes I finally got through the history. Mind you...it usually takes me 10-15 minutes to get a full patient history.  After presenting the history to a doctor I  had to leave so unfortunately I could not follow up with the patient.  When I came in the next day she wasn't on the ward list so I assume she didn't need to be admitted to hospital, which I guess is good news.

All in all...interesting week. It was an introductory week so it was quite light and I took things slowly as I found my bearings around the hospital. Next week is my theatre week so lots of surgeries! I can't wait!

Progress.

I was watching Junior Doctors earlier on and listened to the FY1 doctors saying how they feel more like a real doctor as they have responsibilities and they get to do procedures. I sat on my couch thinking about my last placement on paediatrics. Thinking about it...comparing to my placements just only half a year ago when I first stepped onto the wards as a student doctor, I have seen myself progress. My last placement in paediatrics, I was clerking in patients and presenting the patient history and examination findings to senior doctors. I am probably one of the first "medical" person on the ward to properly sit down and ask them about what has brought them to hospital. I get the honour of seeing these patients prior to the doctors on the ward. While on my placement, I guess I didn't really appreciate this properly as I just took on the responsibility to clerk the patients in, but never realized that I could be one of the first people to see the patient on the ward. I also have to make sure my patient histories are accurate and that my examination is accurate as when I present the history to a senior doctor, it is now expected for me to have a differential diagnosis, possible investigations, and management. Only half a year ago, I was stepping on the consultant's heels going around on ward rounds and just watching. I didn't really get to do very much. If there is something interesting on physical examination that the consultant sees/hears, then he/she would let us take a look/listen. Now...I am the one telling the senior doctor about hearing something and I have to be confident about it. It is actually quite frightening. There were times where I heard crackles at the base of the chest, but I would sometimes doubt myself as they are fairly faint crackles. However, when I present the patient to a senior doctor I have to be sure about these crackles and now I get to write into the patient's notes about any examination findings. It's pretty crazy how much I have progressed from half a year ago.

Also 2 weeks ago the first year medical students got their quick taster of hospital placements and for once I wasn't the most newbie medical student around. There were people more "new"/fresh than me. It was a weird feeling. Then you start noticing that they really don't have a clue how to take patient histories.  And then you think to yourself...about 2 years ago...I was just as clueless. It's weird thinking how much you learn in such a short period of time. Now the structure of patient histories come naturally and you don't really have to think about it. You just ask the questions and go with the flow. I still remember in first year constantly trying to remember what questions to ask...what is important to ask...what the structure is to take a patient history. In first year before I saw a patient, I always wrote on my paper:

PC (presenting complaint)

HPC (history of presenting complaint)

PMH (past medical history)

DH (drug history) - ALLERGIES?

SH (social history)

FMH (family medical history)

This structure is now engraved into my head...and it's only been 2 years! I also taught these freshers how to take a pain history. It's weird that they don't know SOCRATES. SOCRATES is my saving grace. You can never go wrong with it!

Site (where is the pain exactly?)

Onset (when did the pain first come on?)

Character (what does the pain feel like? can you describe it to me?)

Radiation (does this pain go elsewhere?)

Associations (are there any other symptoms that you noticed?)

Timing (does this pain come on at certain times? does it come and go? is it constant?)

Exacerbating/Alleviation (what makes the pain better? what makes it worse?)

Severity (on a scale from 1 to 10 - 1 being not very painful and 10 being the worst pain you have ever felt, what score would you give your pain?)

I found it very confusing to actually see these medical students taking me seriously and genuinely absorbing what I was saying. I'm not much older than them...one of my students was actually older than me! Also when I walked by a few of the first year students and quickly said "Hi!" to them as I walked by, I heard them whispering: "Whoa an older medical student said hi!" I still remembered when an older medical student said "Hi" to me while I was in the hospital...I felt quite happy as I felt like I was noticed and not ignored....more like I actually existed!

Crazy how 2 years make such a big difference, yet thinking about it...it hasn't been too long ago. Speaking of which...this month actually marked the halfway point of my career! Halfway to being a doctor! Scary!