Sunday, 20 November 2011

How not to answer a question

Achievement unlocked: Completed first surgical placement
Status: Acceptable

Some consultants like you to stay quiet if you don't know the answer, some like you to take a guess because "I don't know is never right". But all of them like you to think systematically, to have a pre-programmed structure to your answer. There are some classic questions a surgical consultant will fire off and expect a quick, concise answer in reply - answer that can only be achieved by applying logical, systematic thought.

When we're taught this way of thinking it is generally with a smile on the face of the lecturer and a remark about how you can use the answer to avoid actually having any specialist knowledge in the topic or in actuality, having an answer to the question. If that sounds a little convoluted, allow me to demonstrate:

"What are the complications of this surgical procedure?"
"Complications of surgery can be divided into immediate, early and late, and further sub-divided into specific to a given operation or general to all surgeries. Immediate complications arise during the procedure or in recovery, early within 48-72 hours, late within weeks of the procedure..."

Do you see how that answer isn't an answer at all? And how it is completely right at the same time?

At first I thought it was a technique to bore the consultant and get them wave you into silence, firing off the next (and generally harder question) at the student next to you. But then when I thought about it a bit more, I realised this is such a useful way to manage your knowledge. Rather than having a randomly assorted list of things, you can partition them off, divide them up to help guide your care and treatment modalities with a clear understanding of the most likely cause and the relative seriousness of the complaint.

Whilst there having been important take-aways from this placement, such as the fact I don't think I'm going to be a surgeon, or how busy and yet elegant the anatomy of the hand is, the notion of systematic thinking and how to apply these kind of techniques to make me a better doctor is my top learning point form the past six weeks.

Friday, 4 November 2011

Fighting Trousers - Professor Elemental

Well it made me laugh and not just because he raps about "chap hop".

Poppin' my cherry

I couldn't see his mouth move, but his eyes were firm but kind:

"Is this your first time?"
"I want to hold this, and pull firmly up and back. Easy, not that firm"

His guidance was even-handed, congratulating my successes and admonishing my failings:

"When I want you to hold it, I'll pass it to you"
"No, you're holding it wrong, wrap your thumb and ring finger around it, and use your other hand for support..."

Oh dear.

Sorry, I thought of this post on the tube home and I couldn't resist. Today was my first day scrubbing in on surgery and it was brilliant. A lot of my coursemates have had negative experiences in theatre which has really impeded how much they get out of their surgical rotation. In medicine the classical educational concept is "teaching through humiliation"which is not without it's merits (I will never forget the complications of gallstones after a registrar took my umm and ahhh laden answer to pieces), but when you're in theatre, being told to GTFO because you didn't know the innervation of a particular muscle is just mean. Yes, you should bone up on stuff before your placement and doubly so if you know the operation you're likely to be scrubbing in for, but if you don't know the answer to a particularly esoteric question you shouldn't lose the rest of your potential learning.

I was felt so nervous scrubbing in but I think I really lucked out with friendly and helpful nursing staff and a my registrar being a great teacher. I was ended up in a procedure I wasn't expecting and hence couldn't answer a fair number of his questions (none of which were unreasonable), but my answers of "sorry, I don't know" didn't earn me a sound bollicking, but rather an answer and an explanation. I will not forget that the things I learnt, feeling like a plum and quietly turning red.

And I'm looking forward to the next time I get to scrub in.

Oh, come on!

So, here I am half-way through my plastic surgery placement and loving it.

It took a bit of time to get started, but mainly because I didn't play to my strengths enough and was a bit of a wallflower.

No longer.

I'm getting on well with the team and it's nice to be getting stuck in with history taking, wound washout and dressing, bleeding and cannulating like a mo' fo' and seeing some fascinating cases.

I've really been boning up on my theory, too. I can talk on the difference between an FDP versus and FDS injury, the need for aggressive management of necrotising fasciitis (or "nec fash" as we say in plastics :P), the implications of loss of sensation of different digits or why surgery is so much better than medicine (I'm still not entirely sold on that argument...)

Sitting with the consultant in his clinic still generates existential dread, though. I'm not sure that ever changes, to be fair, as I have seen SHOs and SpRs with an expression I recognise - the "oh god, I have no idea" face. I thought I was doing okay on my last clinic... Only to have One Of Those Questions come up:

Mr Hand: "What test am I asking the patient to perform?"
(the patient is making the familiar "inverted prayer" I know is Phalen's test)
Me: "Phalen's test"
Mr Hand: "And what is the positive Phalen's sign?"
Me: (silently sighing with relief) "Pain or tingling in the hands"
Mr Hand: "And when did Phalen write his paper on this test?"
Me: (OMFGWTFBBQ) "No idea, sorry"

I almost laughed because I thought he was being hyperbolic. Turns out, not so much.