Thursday, 16 February 2012

The Moscow Rules

A helpful reminder

"Only the Sith deal in absolutes"

- Obi Wan Kenobi

Aside from the grammatical horror of that statement, I'm inclined to agree with the sentiment. It is very hard to abide by a strict, unbreakable set of rules. I suspect every rule has its exception and to deny that is to blinker your imagination to how complicated life can be sometimes.
That said, I try to live as moral and ethical life as possible and I keep next to my bed a postcard from the International Spy Museum in Washington, D.C. which outlines the "Moscow Rules". I'll leave you read to about them - suffice it to say they were simple, incisive rules to live (and survive) by for western agents during Cold War in the USSR. One of the things about them I like is that they can be adapted to many different situations, including the world of the medical student.

The Moscow Rules for Medical Students

1. Assume Nothing

Starting any answer to a senior's question with "I assume..." is almost guaranteed to get you a telling off. And rightly so. Equally, if the consultant says "Oh, we start around 9am", don't assume that you should turn up at 9am. Turn up at quarter to 9. Be seen to be eager - no one likes the guy who does the bare minimum.

2. Never go against your gut

In a similar vein, a firm, logical, wrong answer is better than the hesitant, mumbled right answer. You think you know the answer? Say it. Worst case scenario is you are wrong. When you are asked a question, think about the answer and say it. Don't "ummm" or "ahhh", it shows you doubt yourself. Would you trust the doctor who isn't sure of their own answer? Just don't leap in with an answer that you've not thought through. If you think that enlarged liver is Wilson's disease you better be ready to back it up.

3. Everyone is potentially under opposition control

You know how well you get on with that FY1? Just remember that they are there to do their job and you are there to learn. Same goes for the nurses. They're not there to be your friends - be friendly towards, certainly, just don't suppose that they should be used as a confident about their consultant or colleague who they know a whole lot better than they know you. I'm not saying that they'll tell on you, but it will colour their opinion of you, for sure.

4. Don't look back; you are never completely alone

You know how you said that funny thing to your coursemate at the nurses station about that patient with dementia? Chances are the nurses heard you, the patients in the nearby rooms heard you and, if you're very unlucking, your consultant who was just turning the corner heard you, too. Your behaviour should be professional and reflect the role people expect from you. 'Nuff said.

5. Go with the flow, blend in

Everybody has different ways of doing things, especially so in medicine. Every consultant likes a patient presented in a slightly different way, every FY1 has different tricks for cannulating that little old lady with the invisible, almost unpalpable veins. Learn from everyone, it will all come in useful one day. However, remember that your uni has a prescribed way of doing almost everything that they will want to see in the OSCE at the end of the term/ year.

6. Vary your pattern and stay within your cover

You are a medical student and people will generally have low expectations of you. Challenge this by getting involved with as much stuff as possible. Yes, you could do the ward round, lunch and then spend the afternoon doing bloods and cannulas, but didn't you hear the consultant mention a radiology meeting or MDT meeting after lunch? Being a med student is a license to go and see things and be involved in things that you just won't have the chance to do as FY1. Remember that.

7. Lull them into a sense of complacency

Maybe "lull" isn't quite the right word, but it's the first word that comes to mind, to misquote Chuck Palahnuik. If you want to be involved the more interesting aspects of ward life, be seen to be the one who rises to the challenge and succeeds. Hone your skills and show that you know how to work without direct supervision (and when to ask for help) if you want to be given the more challanging stuff.

8. Don't harass the opposition

The opposition could be anyone depending on how bad your social skills are! Don't harass anyone is probably a clearer way to intepret this rule. You know how they teach you that the nurses are pretty much the doctor's hand-maidens (even now, in the 21st century)? They're not. They don't live to serve you, they're not just waiting with baited breath to give you a job to do or to answer your questions. This extends to physios, OTs, SaLT, the whole nine yards. Respect them, learn from them and be friendly and helpful.

9. Pick the time and the place for action

Oh man, this question is burning a hole in me, I got to get an answer, how else will the consultant know how smart and insightful I am? If you have a question to ask, a skill you'd like to practice, be aware that the patient you are with is a human being. Do you think that the history they just gave of weight loss, night sweats and haemoptysis is indicative of lung cancer? Wait until the patient is out of the room and the doctor you are with has time to properly discuss your differential.

10. Keep your options open

Every new placement reminds me how interesting I find medicine. In the UK, at least, you won't have to follow single path in your career until your ST years (and even then people have been known to change). Try a bit of whatever sounds interesting in med school. Don't get fixated on how there is only one career for you in medicine, or you might miss out on something better.