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 unlucky, 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.

Clubbed to death

Causes of Clubbing

A friend of mine wrote this rather neat guide to the causes of clubbing, for those times when you want to wipe that supercilious smirk of the Reg's face following the question "Well, what does clubbing mean?".

Add him on your RSS reader of choice and follow him on Twitter - he does this kind of thing more often than is entirely healthy for a med student!

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.

Getting hands on

Mr. McGuire: I just want to say one word to you. Just one word. 

Benjamin: Yes, sir. 

Mr. McGuire: Are you listening? 

Benjamin: Yes, I am. 

Mr. McGuire: Plastics. 

Benjamin: Exactly how do you mean? 

So we've had six weeks of PBL tutorials, statistics and communications seminars and clinical skills sessions and now, like so many baby birds, we're being let lose from the nest lecture theatre to fend for ourselves. For a bit.

My first rotation is 6 weeks of plastic surgery, allegedly with a hand specialist. Which carries all manner of silent terrors for me as I find the anatomy of the hand and forearm crazy complicated. And being in a theatre gives me all kinds of opportunity to fail to observe some anachronistic aspect of human interaction and get bawled out for my troubles.

But the upside is I have a fair bit of post-surgical HDU nursing experience and know the general tone of surgical ward life. And in many ways my current form was birthed on the wards of an NHS hospital. I don't mean that in a creepy "buffalo bill" kind of way (well, maybe a little bit...), but who I am now is very much the product of having lived and worked in the healthcare environment for quite some time. I hope I can fit back into the pace of things like a hand in a glove. No pun intended.

And then there is the undeniable fact that surgeons are the people who reach into the very living flesh of another person and fix them. This is something incredible to be sure. I can understand where the idea that surgeons sometimes see themselves as gods might come from - If you can make someone better with your hands and bit of know-how, you could forgive yourself for being changed from the experience, too. I look forward to seeing the fixing happen first hand (again, no pun intended) and to find out how the life of surgeon actually works, when they're not writing up post-op fluids or taking down dressings at 9am (don't get me started...)

I don't know if I am a surgeon (though I have nursing friends who promise to disown me if I become one!) or a medic, and to be honest, I don't know if it's relevant for me to wonder this without more experiences to form an opinion. To pass the first year without resit or hinderance showed me I can do this, that I am med student (hear me roar!). What I make of my opportunities and experiences waits to be seen, I guess!

PS There will be Malta pictures, once Flickr stops being in a strop with me.

Where do we go from here?

I've not blogged in a while and I feel pretty bad about that. It undermines the first rule of blogging, which is "Always Be Creating Content" (he said, paraphrasing Glengarry Glen Ross).

That said, it's been a busy few weeks for me. There were end of year results which were thankfully passes across the board. My school gives you percentages, the mean, the pass mark and (as I think I've mentioned before on this blog) a mark of A for acceptable, CC for cause for concern or U for unacceptable. So, for the first time in a while I'm a straight A student, though in real money I'm a slightly above average student which I'm totally happy about.

It wasn't until I received my grades for this year that I realised where I was in my life, academically speaking. I'd approached medical school with a "I wonder how far I can get" attitude - Which is to say at every step of the way I've not been living and dying by the result. I passed the GAMSAT (the Australian version of the MCATs) and was pleasantly surprised. I passed the interview and was pleased again, but I hadn't walked in with the fire of a zealot in my eyes (which I think helped - some people want to be a doctor so much it hurts their chances). Repeat for every exam so far, apart from this last set. I guess that previously I have been a nurse in my mind. Like some kind of interloper, a spy from the wards seeing how the other half live. Learning about the bigger picture beyond bedpans, food charts the myriad other tasks of nursing.

Not that I wish to denigrate nursing, far from it. Whenever people ask about why I went from nursing to medicine (something that happens with regularity on the wards whilst I'm bank nursing, I've discovered), my answers fail to satisfy. The best I can come up with is that I want a different set of challenges. The stuff that really stresses me out in nursing is organising discharges and chasing down junior doctors to remind them to do paperwork or arranging transport or chasing pharmacy for drugs I need sent up *now*. It was stuff that would forever plague me as a nurse and really took the shine off the stuff I genuinely enjoyed - people and their problems.

I'm sure there will be plenty of paperwork BS in doctoring, but it also opens up a world of other challenges that I think will outweigh the new stresses.

The point I'm trying to get across in a ham-fisted way is that having passed the first year has made me realise that I am all in. I really want to be a doctor and I'm less a nurse than I was this time last year. I am changing. There will always be a part of me that enjoys the intimacy that nursing affords, but I am becoming Other. It'll be interesting to see where this goes.

Hyperarousal

A lecturer this term stated that, physiologically speaking, you can only maintain an adrenaline-fuelled state of hyperarousal for about 60 minutes. This was disputed by some of the ex-soldiers in my class, but I guess for civvies like myself, it sounds about right.

I held tightly onto this when the OSCE's came around. Written exams never provoke the same level of sympathetic response in me. It's not because they're a "you know it or you don't" event so much as they're a "sit on your arse and only move your hand event".

OSCEs by comparison are a full-systems-go-hello-my-name-is experience with actors or simulated patients and an individual examiner. OSCE stands for Objective Structured Clinical Examination and is just that. There is a task to be completed. You're running through mental check lists: Look, Feel, Percuss, Auscultate if it's something like a cardio exam or Passive, Active, Resisted when you're examining someone's wrist and elbow or even the classic History of Presenting Complaint, Medical History, Family, Social, Medications, Allergies when you're taking a history. You stand outside a cubicle, a buzzer rings, you read your handout, figure out which checklist you're going to need, memorise the patient's name, another buzzer rings and you're in.

You learn to introduce and consent in roughly ten seconds. Maybe 20 if you need to explain a more intimate exam. You're gently smiling, making the right amount of eye contact and trying to remember the first point of call on your checklist.

Checklists beget checklists beget checklists. Remember where you are. Comment on what you don't see. You can't be negatively marked so call out everything. Start at the hands, don't miss the capillary refill.

I sat in the one of my uni's many coffeeshops with my course buddy CRM and we listed 10 things to look for in the hands alone. Just call them out, you're bound to hit most of the ones you need for this specific exam. And anyway, in real life, you'd be looking for everything anyway, not just the finger clubbing of respiratory issues or the leuconychia of hepatic problems.

So back to my lecturers comment. when I turn up to uni before the exam, I sit on my adrenal response. Lots of revision of my checklists, not thinking about the exam. Drink me some coffee, try a little synthetic stimulant replacement. About 30 minutes before the exam, I imagine what it must feel like to stand at the door of a plane in the sky, about to do a parachute jump.

And Woosh

There it is.

At my word, unleash catecholamines.

Energy, alertness, fine tremor, my sympathetic response. My ancestors used this to run from wolves, I use this to stay focussed on a simulation of real life for 50 minutes. Which, incidentally, really doesn't feel that long when you're doing it.

But it's over for another year (god willing and I don't have resits).

I didn't have to revise anything today. It felt amazing.

So, Google+

So I finished my Musculo-skeletal exam this morning and came home to find a Google+ invite in my inbox. It's pretty neat and I can see me enjoying using it more than Facebook - if my cadre of friends get involved.

However.

If you add people who aren't on Google+ yet to a group and post a message to your profile that they can see, Google+ offers to send them an email. Useful right? Not so much if you've lumped everyone together and you say something which your friends might find funny, but your parents/ in-laws not so much

At first I was like

But then I was like

I've spent the last 4 hours furiously revising clinical skills. And will be doing that tomorrow. And Sunday. So whatever. Ask me about finger clubbing and spider naevi and sub-acromial bursitis.

I dare you.

barriers to revision

It's too durn nice to be stuck inside revising all day. I think I'll go for a run at lunchtime.

Exams

[insert obligatory post about exam season here]

Seriously though, I'm looking down the barrel of exams I feel unprepared for on topics I'm not particularly interested in.

Consequently I've not had time to think of something interesting to say about the psych lectures we've been having recently, other than I'm quite enjoying it and I'm actually looking forward to the idea of a mental state interview in the OSCEs this time around.

And I'm dog tired. I think I feel a bit burnt out and look forward to a summer holiday free of medicine. Just got to head down and just get it done.

P.S. the upshot of doing psych lectures at this time of the year is I can tell how well I am/ am not coping by asking myself all the screening questions about anxiety disorders!

On illness and Admin

From jk5854's flickr photostream

So what started as a bit of pharyngitis has made a concerted effort to claim everything south of my carina as lebensraum by way of a detour up into my nasal cavity.

This led to me taking today off school as I didn't really want to spend the morning mouth-breathing my way around the DR and then spend the afternoon coughing and spluttering my way through the expert forum (kind of like a Question Time for the week's lead lecturers).

This in turn gave me a day to spend either lying in bed feeling a bit sorry for myself or, once that got boring, addressing issues of admin. A close friend on the course is an army type and has introduced me to all sorts of interesting turns of phrase: "popping smoke", "bring the rain", "danger close" and "admin". This is a phrase that covers everything from polishing your boots to packing your bags to making sure you're carrying enough ammo. There is "good admin" and "bad admin". And I have, of late fallen into the latter camp.

So once the paracetamol, phenylephrine and industrial grade caffeine had kicked in I set to my admin. I've cleared up quite a few bits of IRL BS this week and this morning was an opportunity to finish up some notes, send off emails about next year's project to the person who will hopefully be my tutor, pay some bills, secure my place in next year's Brighton Marathon and then have a bath.

And it was everything I thought it could be. I got to lie still and read for pleasure (something I'm not very good at giving myself time to do) and then I washed from top to toe, had a shave and felt almost reborn by the end of it. I'm still working my way through Full Catastrophe Living and the more I read, the more the idea of giving myself a few minutes everyday of paying attention to my body seems healthy and appropriate.

I find it slightly ironic that I need to be sick enough to not go to school to force me to stop for long enough to just "be". This is something I need to work harder at doing. That and paying attention to my admin.

Panniers

So I've been cycling to school for a while now and have been getting increasingly bored with sweaty-back syndrome caused by carrying my capacious backpack. So in a bid to treat this frankly life-altering condition (carrying a spare t-shirt, knowing that if it rains my books will be soaked, getting my sweat on with the least amount of exercise) I bought a pannier rack and this badass pannier bag.

And the change has been dramatic. No more sweaty back, having a waterproof storage medium (it's made from super hardy trucker tarp), it's large enough to hold my smart dress for clinical days.

It's all good. If a little dorky.

Incidently, this was meant to be a test post of emailing a post from my iPhone. Turns out you need to be careful with your formatting. Duly noted.

"You've not blogged in a while, have you?"

Thank you, Liz!

My apologies for not having posted in oh-so-long. It's not that I don't have anything to say - I am the kind of dude who always has an opinion and little needs to be done to wheedle it out of me. I am however, the kind of dude who also has priorities and sadly med school has taken up my mental runtime a bit too much of late. I'm not suggesting that I've kicked it into high gear and I'm producing more work than previously, it's just that the work is taking up more of my conciousness than previously.

I guess it's not a useful place to be in especially, but I am doing what I can to nip it in the bud and try and remember how to work *and* play.


Can I direct you to a podcast about priorities? Well, I'm going to anyway. Back to work is a nominally a podcast about business practice (don't worry, it's not as dull/ pompous as it sounds), but a fair amount of the issues that Merlin Mann addresses are relavent to study, too - especially when he starts banging on about priorities and "what can you not ship?".

Can we talk about not doing, too? This is another step I've taken to address the general horror of medical school. I've started practicing Mindfulness which I hope will be fruitful in future weeks. I picked up a copy of Jon Kabat-Zinn's "Full catastrophe living: using the wisdom of your body and mind to face stress, pain, and illness" from the school library and I'm working through it slowly. There's a lot in there and integrating 15mins (and working up to 45mins) of meditation into my daily routine is not easy in terms of finding time. I am learning to be more in the moment and observing what is happening around me without judging it. I am *not* turning into some kind of crunchy beardy type who moves to Vermont and knits their own yoghurt - I am turning into someone who is more in control of their life. There will be more on this as I pursue mindfulness.

I've started a pilates class before school starts, too. Turns out that standing an breathing is waaaaay more complicated than I thought. Just as well I found out now so I can do something about it before the situation gets any worse!

We've transitioned from musculo-skeletal to neuro and psych in modules at school. The former reminded me that I am not a surgeon and after yesterday's primer on neuro-anatomy, I think I can rule out neurology, too. I did enjoy dabbing at coursemates with cotton wool though for the sensory neuro exam, though. Psych is something I have limited experience with, but I look forward to finding out about it and the idea of an assessment that doesn't involve touching someone is novel to me!

First days of Summer

Like having your own private pool

In London there are several Lido's (open air pools) dotted about and seeing as how we've entered April, some of them are opening for business.

A friend of mine suggested going for a swim on Tuesday night at our local Lido and I thought "why not?". The great thing about going for a swim in an open air pool in the middle of April is that no-one thinks this is a good idea, so you rather have the pool to your self. Just remember your wetsuit.

The not so great thing about it is how cold it is. I didn't mention these are unheated pools, did I? Now I'd heard how being dropped in cold water can suck the air out of your lungs but I'd never experienced this. Turns out it's about as much fun as it sounds, and swimming in cold (the air temp was around 10 degrees Celsius, make of that what you will) water is a hell of a lot more tiring than you might expect.

We briefly (half a length) practiced some front crawl, until the pain in our frontal sinuses was so great it made our eyes buzz. Then we changed over to some old-school, head out of water breast stroke. It was a lot of fun, we swam about 1km at a very reasonable pace and even had a bit of chat whilst we went. I think we'll be back next week.

Obligatory London landmark shot

Yesterday was a fair bit warmer and meant that cycling to school was glorious. We had PBL all morning (case of the week: RA) and towards the end of the session there was an almighty crash outside our room and plaintive "can I have some help, please!" was heard. Ah, I thought, that's not good. I opened the door and narrowly avoided a pool of something brown. Iced-coffee. A young woman was kneeling next to her friend who lying on her side in the corridor straight and stiff as an ironing board, jerking slightly.

Seizure, right.

"She's having a seizure," the friend said "She's got a history of this, but I've never seen her this bad."

The girl having the seizure was grunting through a clenched jaw, but I could seeing nostrils flaring so I was pretty happy she had an airway. We rolled her onto her side just to be safe, though. I ducked back in the room, past my classmates who had got up to have a look. Because I'd cycled in, I had my emergency trousers in my bag (my thought being "get something soft under the patient's head). I managed to gently maneuver them under the still seizing girl's head. More people came out to see what was going on, a couple offered to call someone (even in the medical school the crash team will come running) and I directed the rest back to their rooms. I knelt behind the girl's shoulders letting her ride it out saying supportive things to the friend. It occurred to me that there wasn't much else we could do. Airway? Yup. Breathing? Yup. Circulation? Uh huh. Waiting 'till the crash team turn up? You betcha.

A couple of doctors sprinted up the corridor, the friend gave a potted history and I went back into dicussing RA. Slowly more people turned, there was monitoring attached, oxygen given and she looked like the seizure had stopped and she was going postictal. Good, I thought, now how do I get my trousers back?

A case of the Mondays (again)

Overslept
faffed around
jeans crumpled after they've been tumble-dried
No time to make the bed
Waited in line at the train station, only to find I had money on my oystercard
Missed my train
Running late
ATM only dispensing 20's, no 10's

Realise school starts an hour later than I thought.
Been sat by myself only to have a good friend say she'd been here for an hour downstairs.

Hilarious.

P.S. These diamond shoes are too tight and all these Benjamins won't fit in my wallet.

Knowledge-worker hands

One of the things that revision time always gives me is time to reflect. Nominally, I'm sat on my bed looking through powerpoint presentations, or reading old notes, trying to condense pages of information into bullet points so that I can remember and regurgitate it on demand.

Revision is boring. Occasionally I have learn something for the first time because I missed (by choice or by the fairly dreadful course planning) the lecture, but mostly I am revisiting or, indeed, revising, my knowledge base. Whilst I slog through the material I will confess my mind starts to wander a bit, and one topic that I keep on coming back to is my role in life as a man, whatever that means. And like any good physical exam, I start at my hands.

The phrase "knowledge worker hands" I stole from Merlin Mann, and it refers to that nice soft palm and fingers experience that comes from living via the keyboard or whiteboard. When I nursed, my hands were invariably dry or cracked from the alco-gel or the soap I used dozens of times a day. There were callouses from pushing and pulling things all day long. I came to see them as nurse's hands. Working hands.

Since the start of my course, my hands became softer, better hydrated, fewer (if any) callouses. And I have begun to feel a certain disdain towards them. Maybe it's a loss of identity, or a natural distrust I have of soft hands on a man (utterly ridiculous, I know), but my hands became knowledge worker hands.

I've started climbing recently and I now sport callouses and scrapes and an ever increasing grip strength. I've started practicing Aikido again, after many years away from it and realised that I had lost any sense of the "killer grip" my new sensei talks about. The grip that when applied to your wrist causes your hand to claw up. I've picked up my guitar again and I notice my fingertips are soft and hurt after a short time of playing. I wonder if this is all a response to how I see medicine in some way. I know that it is hard and demands so very much, that surviving the long hours and ability to think on your feet is a skill. But my hands soften and that bothers me on a very fundamental level. I don't really understand why. Maybe this is material for a midlife crisis that's just been delivered a few years early.

My feet are runner's feet. My hands must not be knowledge worker hands.

Go figure.

Acceptable, again

My school has an interesting way of grading our exam results: Acceptable, Cause for Concern and Unacceptable. You also get to know the range of the class’s score and the median result. But no A’s or B’s or curving the grade.

And I’m acceptable. More accurately I’m a bit above-average. And that is something I’m entirely happy with, because frankly, I’ve needed a win for a while now. I’ve been bogged down in feeling like I wasn’t good enough to, like I should stop this nonsense and head back into nursing where I could make a buck, be good at something and not feel like I was a pretender. My grade for the mock OSCE put me a little above average which is where I have been throughout my educational career. Primary school, secondary school, A-levels, previous university life - above average. Not top of the class, not a notably able student who’s full of promise, just a pretty good student.

So I can go into revision for the next round of exams (2 and a bit weeks time) with a more positive feeling than I went into the mock OSCE. And I've just finished a weekend at the family homestead, being fed and watered, drinking someone else's booze and seeing how my father is getting along. Aside from not being allowed raise his arm above his head, he's doing just great, which has also taken a load off my mind (and his, I rather suspect - and the rest of the family!)

Which reminds me, thanks for all your continuing words of support and comfort, it's really meant a lot to me.

I hope you've all had as good a weekend as I have :)

Uh oh, part 2

Right, well then.

I guess this is going to happen more and more. I've not sworn people to secrecy, but I'm not going to mention it in class. Primarily because I don't want to be "everyone read my blog" guy in class. If people find it, read it and figure out it's me, fine.

It does raise some interesting issues around confidentiality, though. I've asked one of the ethics lecturers about my potential concerns about blogging and the impact it might have on my standing with the British Medical Association re: appropriate behaviour for a medical student. He said he'd contacted the BMA and the MDU (medical defence union) about numerous issues around breaching confidentiality and said he'd not got much in the way of a firm answer. This came up because he'd lectured us on how discussing your day with your spouse was a breach of confidentiality (at least in a literal, textbook way), even if you changed the names to protect the innocent and whatnot. I know most medical types shoot the shit in the pub after a bad shift, talking in generalities in public, and most might unload to a wife or husband or whomever at home to clear their heads - never mentioning a name or age or ethnicity or anything that might identifiable information. That this is fundamentally a breach of confidentiality, I find troubling and a little difficult to wrap my head around. So that gave me pause for thought about all of this.

Certainly within the field of blogging, we all say we anonymise patient information but there is always the chance (however microscopic) that someone might recognise themselves and decide to pursue legal advice - something no-one wants to have happen. My lecturer seemed to think that there weren't any hard and fast rulings on issues of confidentiality re: blogging because no case had come up yet, coupled with the fact that the BMA didn't want to prevent doctors (and presumably medical students, too) from what is arguably reflective practice, albeit done in public.

I have seen some people have signed up to the healthcare blogger code of ethics which I think is an excellent idea and I have every intention of signing up after I finish this post. I mean to behaviour in an ethical way and never to breach a patient's (or a co-worker's, for that matter) confidentiality. It is so essential to medical practice, so very valuable to a healthy and successful relationship with your patient or your own healthcare provider, that we should never belittle it. It is a standard that we should hold as high as any other as it reflects on us as professionals and as people, too.

As for my blogging, no-one has suggested anything I have done is inappropriate and this is something I coming to value more and more as the course becomes more demanding. So I shall keep on as I am doing until I hear otherwise, hopefully entertaining and maybe even educating y'all as I spill my brainguts to the internet at large.

Twofer

Yesterday was something of twofer for me:

1) Onto the wards (briefly)! Practiced history taking with some lovely patients who were both engaging and actually knew the details of their medical history. It was great to sit and talk, smile and commiserate (not simultaneously, I hasten to add) and generally play Healthcare Professional. I even got to practice some skills (TPR, BP etc.) which was a nice opportunity to flex a little muscle memory and gave me chance to flick through the end of bed notes. It looks like St Clabert's uses very similar paperwork to the stuff I've used before, so that was comforting.

I've realised that I'm the kind of person that will use this blog to voice the times I'm really not in a great place, but I hope that I can use an equal portion of it to the times when things are going really well. I think it's just a facet of this year that due to its pre-clinical nature there will be more of the former than the latter ;)

2) I used to set-up Octreotide infusion for patients undergoing liver resections or Whipple's procedures and never really understood why. There was something called "carcinoid prophylaxis" that I was doing, but I never had the time to look into what it was and the relative importance of it. I knew that it could cause merry hell with their blood pressure and was potentially dangerous, but not the why behind it. That all changed when I talked with one of our lecturers who was a consultant endocrinologist. He was a really nice guy, who engaged with the class and spent a happy hour dropping knowledge bombs. It turns out that octreotide is a potent analogue of somatostatin and has a similar mode of action. We were using it pre-operatively to reduce the secretions of carcinoids - a bit like in this paper. This is the kind of knowledge I find really sticky. It interests me, has a clinical link and I can see this sitting in my brain for years to come.

How much is enough?

words of wisdom from Wonderella

Today was rectal exam day.

But more importantly, it reminded me how I don't have enough time or energy or ability to be the best.

And how, on a low day, this is really dragging me down.

I don't understand it all, my clinical skill set from nursing is yet to be useful and I am surrounded by over-achievers, Rainman's marginally more socially adept cousin or full-on alpha males. And me, I just want to pass.

I know I can be a good doctor. I know this. Get me on the ward, give me the chance to flex a little communication skill, let me lay hands on a genuinely ill person or something where I can show my quality. I'm tired of the let's pretend of clinical skills where say all the things we don't see (no sign of clubbing, splinter haemorrhages, xanthelasma etc etc) , the PBL sessions dominated by pointless displays of obscure, clinically irrelevant, scientific knowledge, the lectures that wander around the point without actually helping me learn.

I laughed when I saw the entry on Stuff Medical Students Like about "Time". But it's funny because it's true, to quote Homer. I don't feel like there is time enough in the day. It is some small degree of schadenfreude that most people I talk to on the course say this. I think the worst bit of it all is that I feel guilty for any time I spend not doing something to help me with medicine. Go to the pub? Go to the gym? Go to the cinema? This is all time I could better spend learning about Vitamin A metabolism or the pathways of the facial nerve or any number of the myriad little bits of information I need to have at my fingertips, because as one of today's lecturers said:

"One day you're going to be sat in A+E at 3am and not have a bloody clue what is sat in front of you"

And that, I guess, is what scares me the most. That I don't feel I have enough time now to be the best and one day, someone's life may well rest on me remembering that symptom X is a tell-tale sign of disease Y which if not picked up will kill them in a couple of hours.

So I work as hard as I can, but I don't feel like I've covered everything. And it doesn't matter how many times I can answer the lecturer's questions, the one time I can't, some else can - which undermines any sense of confidence I have about the topic. It's sick really.

On the upside, Father's had his angio which showed, to quote the radiologist "pristine coronary arteries", so that's something :)

Bicycle vs. Car

Sooooooooo...

One big meaty hole, to go, please.

I've officially had my first proper crash on the streets of London. It hurt but it was one I could walk away from. I was on the cycle, she was in a car and decided to turn left immediately in front of me. I pulled on the panic handles and slid into the passenger door on her car and then slightly underneath it. Or at least my bike did, I tumbled off to the side and lay on my back for a while considering how quickly everything had happened.

I got up and exclaimed, using some rather salty language how surprised I was at this occurance, and how the woman driving should pay more attention to other road users.

No damage was done to my bike and I seemed to have no more than skinned knees and elbows so we left it at that and went our separate ways.

2 hours into my PBL session and one of my knees was still bleeding from what looked like a puncture wound caused by the head of an allen bolt. As my PBL-mates became progressively more grossed out by the blood dripping down my leg, I decided to head on down to the A+E dept (one of the joys of having your med school attached to a hospital). I got an x-ray for my troubles (and first hand experience of surgical emphysema - it crackles!) and a good scrub down with betadine at the hands of the A+E consultant.

It's not going to stop me riding around London, though I might go a little slower. I'd forgotten how painful it is to have a hot shower with skinned knees.