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.

Orthopaedic Clinic.

A bit hard to believe but I've only got 2 more weeks of Orthopaedics left. It definitely flew by despite not being a very "intense" placement. Actually it was extremely slack...but it still went by very quickly as I'm still having fun and having a good time. With this particular specialty at my school, students aren't placed in Orthopaedics for very long. Through the regular rotations through the school we only get about 1 week of Orthopaedics so consultants/registrars don't get to know you very well. With me, because I had self-designed my placement to be in Orthopaedics for 6 weeks...consultants find it weird that I've been around for a lot longer than most people. Every week I attend early morning meetings to discuss about cases and I can tell that the consultants are starting to expect me in meetings and I'm becoming a familiar sight. They are all acknowledging my presence and are talking to me, which is a bit of a surprise as I haven't really followed any of them to clinics/theatre so in general the only time they see me is when I attend their meetings (once a week). 

Essentially I go to clinic twice a week, and we would see quite a lot of patients in a half-day clinic. When I first started out on my first week, I essentially just sat in clinic and observed. The week after, I was allowed to go take full patient histories and then present them to my supervisor in front of the patient, but I would watch my supervisor perform examinations on the joints. Third week: full patient history + joint examination on my own, then present to my supervisor in front of the patient. Fourth week (now): take a full patient history, full joint examination, differential diagnosis + formulate a management plan. I think my supervisor is doing a really good job in terms of allowing me to progress and allow me to do a bit more with every week. Finally getting things to do and a bit of responsibility, which is nice. It also makes the clinic a bit more enjoyable as sitting through a whole clinic and not doing anything gets fairly boring, especially in such a specialized clinic (lower limbs). Patients generally come in with the same complaints so when we get new patients, I get to at least get up and walk around and do a bit of talking/interaction with patients in a side room, while my supervisor sees a follow-up patient. I actually think it helps the clinic move a bit faster as we are seeing two patients at a time at some points and when I present my patient, it obviously takes less time than doing a history on the spot and my supervisor is starting to trust my examination findings so he only needs to quickly check instead of going through all the motions.

I think I'm actually learning a lot as my history taking skills and examination skills can always be improved on so with all this practice, I believe I have improved a lot. Taking a pain history is quite easy now and it is something I don't really need to think about anymore and I hardly miss any questions out as I'm seeing so many patients and getting lots of practice in. This is definitely giving me a bit of a head start compared to other students as other students use their "self-design" placement as a holiday by applying to do a project in "sign language" or something really random. With my placement, it is almost like a regular rotational placement that we get placed in and I'm doing a lot of clinical things which is obviously helping me improve and giving me a lot of opportunities to practice and formulate management plans (which aren't really taught to us...it is something we have to learn on placements).

Overall, really enjoying my time in clinics (can't believe I am enjoying clinics) and they go by fairly quickly as well. My supervisor asks me questions from time to time so he keeps me thinking and he teaches and shows me a lot of x-rays throughout clinic as well. Like I said about my last O&G placement, supervisors definitely matter and they can make a huge difference in your placement. Can't believe only 2 more weeks left...I could do another month of this! Starting to become a routine and I'm starting to feel a bit more comfortable. Best bit is that I'm not in every single day from 9-5, so I get to work on a project/audit at the same time so it keeps my week interesting/varied. Plus I'm getting some free time to enjoy the odd sunny weather here in the UK. Loving it.

Practice Makes Perfect.

I was signed off from placement on Monday so I haven't been doing anything particularly interesting other than revising for exams. Met up with a friend on Thursday to do some physical examination practice on patients at the hospital. As you may recall in my first attachment back in the summer (doesn't seem that long ago...time flies) I was drilling Cardio an Respiratory Examinations. Well exams are in 2.5 weeks so I got to get drilling on the rest of the examinations.

So we went and practised Abdominal, Shoulder, and Knee exams. Got that down pretty quickly. Never really had trouble with those examinations to be honest. Then we practised Cranial Nerves, peripheral neuro, and hand examinations. We did these with each other as these exams have quite a lot of steps. Before practising, I was hopeless at Cranial Nerve exams. I was not slick at all and obviously needed some serious practice. After a few attempts, I have finally gotten it down and was starting to get slicker at it. Did the same with the other examinations and I could definitely see an improvement. I was starting to feel much more confident with my examination skills and a bit more confident for my OSCE exam. Have arranged another physical examination practice session for Monday so hopefully I'll continue to improve and get better at these things.

Today I finally reached the last system to revise (Gastrointestinal). It surely doesn't feel like the last unit as my binder is still full of notes and it just doesn't seem real that exams are so soon. It's really weird. Most of my friends and I agree that exams don't seem near and the panic still hasn't set in. Generally been feeling quite unmotivated so I constantly have to remind myself how close exams are which results in mini panic attacks/a kick up the ass. I guess it kind of works as I've been revising furiously for these last few days and really pushing to get ahead of my revision schedule to give myself an extra half week of revision for anything I'm unsure of. At the moment I have scheduled in 1 extra week prior to exams for random revision/going over sample questions. Hopefully if I work hard enough I can make it 1.5 weeks of extra revision time to actually properly learn Microbiology. I swear Microbiology is my new nemesis. It used to be histology, but because we don't do that as much anymore...Microbiology has quickly taken Histology's crown of being my nemesis. There are so many things to remember! And all the stains for the different bacteria. Mental.

Pharmacology comes close behind. Drug treatments for Cardiovascular disease and respiratory are fairly straight forward. The minute you get to Dermatology...oh wow. You start feeling like a walking BNF (British National Formulary - it is a book of drugs)...but more like a BNF written with fading ink. Put some new drugs into my brain...the old drugs fall out. Dermatology...endless amount of drugs. So many names as well! Half of them I can't really spell! I can picture myself writing drug names in my exam and writing the first few-ish letters and then squiggling the rest and making sure it looks like the drug I'm thinking of. Thank goodness spelling doesn't count in our exams! As long as the word is recognizable they will take it.

My Oxford Handbook of Clinical Medicine is also finally getting beat up. It had been in mint condition for 2 years and FINALLY it is getting used...and I am seriously using it to death. Also random note - think I might be getting tennis elbow as my desk isn't great to write on as it is fairly deep. That means my elbow is constantly resting on the hard surface and sometimes I can feel my hand go tingly and numb. Also my elbow is sore from resting on the hard surface. The things you sacrifice for exams. Sacrifice sleep, good food (yay for quick microwave food), social life, going out, sanity, blah blah blah, and now sacrificing joints! Prospective future for my body. YES!

I hate revision. I miss lounging around and being lazy.

Exam Preparation.

To be honest...I haven't really done anything in placement, hence, the lack of updates. As you probably noticed from previous posts, my exams are coming up which involves 2 written papers and 1 OSCE. It's my first year of taking OSCE and doing more clinical based papers, so I'm quite nervous as I don't know what to expect. Yesterday, I finally got an idea what the OSCE will be like though as the school held a mock OSCE session for the students.

Essentially, our OSCE will be 6 stations of patient histories, and 6 stations of physical examinations. Each station will be7-8 minutes long. Before going into the mock, I had an impression that it will be really difficult. To my delight, the mock turned out a lot easier than I thought. Obviously could have done better as I didn't study for it (haven't had time to) or really practice for it. All in all, it wasn't too bad. I do have to work on making my examinations more slick and quicker as I take too long examining the peripheries. For example in Cardiovascular examination, I spend too much time looking at the hands and face. I think I need to just quickly glance over the hands and really just scan it instead of really looking at every single detail. Obviously the most important part of the exam is to examine the chest and I felt that I spent less time on the chest than the peripheries. Again, I think this is down to practising more.

It was really nice getting feedback from people on how I did in the mock OSCE and I now know what to focus on. Prior to the mock, I wasn't too sure what I needed to work on so I will be making a trip to the hospital tomorrow with one goal in mind: get slick at examinations. It should be good and I'm quite determined to get this down as the OSCE is worth 70% of our mark. In terms of history taking, it has always been my "strong point" as I do enjoy talking and I feel that I have a really good logical system of asking questions. In a patient history you would ask Presenting Complaint, History of Presenting Complaint, Drug History, Family History, Social History. Once I get that in my head, I find that asking questions and getting info from the patients quite easy. During mock, I was also helping out and was a patient for a station. Some people don't have a system at all and you can tell as their questions are all over the place. It's nice to see the level of history taking other students are at as it gives me a good idea of how much I need to work on my history taking skills.

Other than that.....3.5 weeks until exams. Eep.

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 Week 2.

Wow this week went by really quickly. One more week and then summer holiday!

So last week wasn't the most productive, so this week I wanted to make sure I get lots of patient histories and examinations done, as well as find a patient for my SSC project. This week I have managed to do about five patient histories and managed to do at least two physical examinations on 3 of the 5 patients. Again today (Friday), was my most productive day. Started bright and early and went to go see a patient my partner and I had taken a history from yesterday. The patient was going to be discharged today so we quickly did all the physical examinations we needed to do for our SSC project. Our SSC project requires us to find a patient where we do a full case history and all physical examinations (Cardio, Respiratory, GI, GALS, and CNS). This patient was extremely nice. I mean he was not feeling well and was quite frail. My partner and I expected him to say "no" when we asked for permission to take a history and examine him, but to our surprise he quickly said "yes" with a big smile on his face!

We first asked why he was admitted into hospital and listening to his history made me feel quite sad. This patient lives on his own and is almost at the grand age of 90 and he had collapsed on his floor at night. Because no one lived with him, no one knew he had collapsed and unfortunately he could not get up off the floor. He spent the entire night on the cold floor and because he had not answered his phone, his son had gotten worried about him and went to see if he was alright. The way the patient described his ordeal made it sound painful and you just feel really bad for the patient. He looked very upset and distressed about collapsing and told us that the pain he had from falling was immense. Whilst talking to the patient, we realized he was quite short of breath and had a constant and productive cough; therefore, we thought we should give the patient a break and would come back and examine him the next day (Friday).

So today we went to see the patient and the nurses told us not to bother the patient because they had just finished ward rounds and had prodded him quite a bit. He also looked quite tired as well and did not look very comfortable. We were then told he was going to be discharged later in the afternoon, so after popping to another ward to join a ward round we went back to the patient and asked if it was alright to do a quick full examination on him. Again, we were expecting to hear a "no" and a "leave me alone!" as he did look quite annoyed; however, he looked at us and promptly smiled and told us that he'll be more than happy to let us examine him. Because the patient looked quite tired, we tried to do our examination as quick as possible to minimize the amount of "prodding" we had to do. At the end we thanked our patient again and he gave us a firm handshake and wished us good luck with our career. He said it with so much sincerity and kindness it definitely brightened up my day. If I was in the patient's position I definitely would not let two medical students poke around and bother me if I was not feeling well. What a kind man and I got to say, my partner and I had learned a lot from this patient as he had an extensive history and was an immense pleasure to talk to.

Also now being my 2nd week of venturing the hospital, I realized that the staff in the ward I am placed in are starting to recognize me and it was nice to see them saying "Hi" to me. Makes me feel like I am not invisible and that the staff do remember there's a medical student wandering around. I even had a lovely chat with one of the nurses as well and finally felt welcomed. Worst part is that next week is my last week and I feel like I am starting to get the hang of being in my ward and getting to know people. The turnover is so quick as each placement only lasts 3 weeks for us (total of 4 placements). Can't believe that next week is my last week! I feel like I've still got lots of stuff to do. I still have to be assessed on doing a patient history and a physical examination by a doctor. As well, I need to find another patient for my second SSC project with some sort of ethics and law background to it, such as discussing patient confidentiality, DNR forms, etc. Not only do we have to do that, but also we need to find our consultant. We haven't seen him since Monday in theatre as he is away for the rest of this week. He said he'll be back next Monday and my partner and I will have to chain him down (as he can vanish into thin air in a blink of an eye) and hopefully arrange a meeting with him on Wednesday morning as he will be free. I will definitely make the most of my final week and I still haven't been in clinic so I'm going to try really hard to go to one next week. It should be good. And then...I'll be HOME! Haven't been back since winter holiday and I'm starting to get really homesick.

Anyways sorry for the long post. Will update next week if I have time!

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!

Hectic.

Okay...I may have lied in my last post about updating my blog sooner. Oddly enough, I did not expect to be this busy. No I am not on summer holiday. I had a 4 week holiday...well 2 weeks after results. Started back on June 6. It has been non-stop 9am-5pm lectures. I have never really had 9-5 days. Usually I would be in lecture for the morning and get the afternoon off. There will be a day here and there where we would get the odd lecture from 3-5 after 2 hours in the morning from 9-11. But I have never had 9-5...non stop. We're talking about 1 hour lunch breaks. Most of you reading this will be like "...9-5 is nothing. What are you talking about?" I find it quite difficult to sit for so long, so by the time I get to the afternoon lectures I am mentally drained and can't really focus. On top of that all my friends feel the need to cram a million events into these next few weeks as we'll be splitting up for placements and all of us are in different hospitals so we will not be seeing each other very much. Can't handle so many dinners and outings!

Anyways my lectures have been mostly about clinical examination sessions, such as how to examine a patient with a vascular disease. Or how to examine a thyroid patient, or how to do a breast examination, etc. Also I finally got to use my stethoscope. Really started feeling like I am studying to become a doctor. It was really weird. The feeling will only get greater when I start placements in 2.5 weeks. Quite nervous and excited at the same time about placements.

We have also been learning clinical skills such as catheters, injections, etc. Crazy jump from sitting around in lecture theatres learning about medical science to suddenly learning how to do stuff that you do on the wards. Finally get the feeling of doing something practical and I feel that I can finally call myself a student doctor.

On a side note the weather has been something. Been roasting this weekend and today. Sitting in a lecture theatre with over 250 students with no air conditioning, and attempting to concentrate for 4 hours of microbiology is almost impossible. It was quite annoying that during the winter the air conditioning would be on and you would be freezing to death, but during a mini heatwave they decide to not turn on the air conditioning. Hopefully they'll turn it on tomorrow, but I don't think it will be as warm.

Anyways these last few weeks have been quite dull so I won't bore you with the details. Hopefully in a few weeks I will be updating you on my first time on the wards as a clinical year student...or as a "student doctor". Hopefully I'll be placed with a good consultant who is enthusiastic to have medical students around.