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.