Thursday, June 14, 2012

Just finished exams; now thinking of exams again

This seems to be rather pervasive among many groups of students, but perhaps only the most nerdy ones... however, this time around, I was not in my nerd mindset - rather, I was in a pretty good place! I just finished my Paediatric OSCEs, and with it, the end of my paediatrics term - which is a bit sad, as the patients were oh so cute and lovely, especially the last one who volunteered (or her mother did?) to be part of our OSCEs. However, my mind was now set on fixing up my elective (hopefully in Singapore), which until now had not been sorted out yet. Setting upon this task with great diligence, a spanner was thrown in the works and I was notified that one of my elective rotations may have to be delayed until the middle of December (meaning that I would be in the hospital during the Christmas/New Years break! Oh how novel! How exciting! How nerdy!). This lead me to consult my academic calendar for 2013 of which I could not find evidence of existing, and then to the Year 5 (i.e. the last year) unit outline.

And there it was, in bold, nicely formatted at the end of a long table of deadlines... the BARRIER EXAMS. 3 and a half years after I had started my degree, I was now exactly 52 weeks - that is, 1 year - away from my final exams of medical school ever! This of course is not withstanding accidental freaks of nature, angry examiners, unfair marking criteria, or simply not studying hard enough this year. So, if all is smooth sailing and the next 52 weeks progresses as the past 170-odd weeks have done in the past, I will be sitting my final barrier exams. Sorry for repeating myself, but I could not get over this fact. One year may be a long time for some, but I find that one year goes by extremely quickly, and before I know it, the year has gone. Much like these last 3 and a half years - apparently, according to my parents, I've barely aged! Of course I am still 1.5 years away from graduation itself, but nonetheless, barriers feel like...well, barriers, and once they're done, graduation is pretty much guaranteed.

There seem to be two peaks of knowledge reached by a doctor - or at least the sane ones who only go into one specialty - the first I feel is right at the end of medical school at the barrier exams, where an enormous amount of studying goes into achieving that final hurdle and making it out. The second is right after successfully finishing the fellowship exams, and it astounded me just how much registrars at that stage knew - many could talk for a good 15 minutes without pause about any particular condition. Whilst less of a demonstrated challenge may be required for medical school final barrier exams, I still feel that this is an expectation I have of myself. Perhaps not many trials and studies, but at least every common disease, and every uncommon disease, and some rare diseases as well. Then surrounding and supporting the pathology would be the anatomy and physiology of which I most likely will have to revise by that stage, the clinical processes, and the treatments that may be recommended. I feel this is most likely a surmountable task which can be achieved with adequate preparation; I just wonder how many of my friends and fellow cohort will be thinking of the same thing.

More than anything though, there is real motivation to study in these clinical years as the finish line draws closer. Exams, sure, are motivation, but for many, they are only motivation for cramming. What really gets the gears moving is the clinical immersion, and the fact that soon enough, you will be on the payroll of whatever state or country's health system you are employed by, and then as an PGY1 (post-graduate 1st year) or intern, you're now in it. Unlike the medical students who you are now swamped by, you cannot choose to do one discharge summary and then head to the "library" to "study". You cannot accompany half the ward round in a dozed state and then leave for a "tutorial". You now have a pager, so now people can contact you if need be. Finally, your actions, and your written record, can be pulled up years from the time and presented in formal proceedings of a court, Medical Board or coroner.

All of this brings about with it a special kind of motivation - though unfortunately the last one does play in many people's minds, for myself it's more about the fact that, yes being paid means you get a relative windfall of money as an ex-student, but also means you're responsible. Combined with the fact that most doctors don't want to hurt any patient more than is required to eventually help them, this motivation is the motivation to become the very best you can be.

And I'm not sure whether some of my fellows, or even myself, fully grasp this. Sure, as I am blogging away about this, contemplating this within the gyri of my brain, I am aware of this motivation and want to eagerly pursue it. However, I am still wont to procrastination and all sorts of fun ways to waste time, though admittedly I have cut right back down on the amount of gaming time. I also wonder about whether I have some priorities right - my heavy involvement with the student representation at university is most likely to end by the close of this year, but for the present, what effect is it having on my overall motivation and efforts in medicine?

My solution to this is simple, and for those who are reading and are medical students, consider: the first principle of medical practice is Do No Harm. This means that, when all is said and done, the most important thing for a medical school is that their graduates are first and foremost safe doctors. No amount of amazing trivia on von Recklinghausen disease is going to outweigh the lack of preparedness in an emergency situation.  Hence, the concerns listed above largely disappear if one were to be considered a safe doctor. At the same time, there are only so many things that need to be done well to be considered safe doctors, and many of them are actually not related to what is taught in lectures and tutorials. Things like being responsible with allocated tasks, always being honest, making sure to document important events and happenings, communicating with and informing patients as much as possible, not going Rambo when there is help available - they are all things that medical schools try to include in their curriculum but never seem fully teach, mainly because it is so difficult. Then of course there are the things that are taught in medical school, but primarily it steers away from book knowledge - how to recognise subtle and not-so-subtle emergencies, how to handle them, how to competently take histories, perform exams and interpret investigations, how to assess whether a patient is fit to send home - these are critical elements to being a safe doctor as well.

By and large though, these things don't require enormous amounts of knowledge, and in particular enormous amounts of book knowledge - but they do require a significant amount of clinical exposure, and the dedication to attempt to gain this clinical exposure, learn from it and then retain it through study. This element is what frustrates me when I know that people are missing on this clinical exposure in the belief that they can compensate for this by simply studying from a book. No matter how 'clinical' the book is, the clinical exposure and bedside teaching simply cannot be replaced, and those who are skipping out on these to go to the "library" to "study" are missing out - but more concerning than that, they're losing opportunities to learn to be safe doctors. I know this happens everywhere, and in other courses as well; I have friends in Engineering who mention how the majority of graduates have a piece of paper that only really serves one purpose, to get them into an entry-level job; and on day 1 most are largely clueless, and continue to be so for the first year or even first few years of their job, relying on various aids available to them. However, this element is more critical for junior doctors, and I can't recall exactly where I heard it, but a man once said: the most dangerous time to be in a hospital is at the start of the year.

So my justification for anyone who does a significant amount of extracurricular or have other priorities, perhaps having children themselves or other life priorities - is that as long as the clinical exposure is there, and the learning from the clinical exposure is present, and you're fulfilling the criteria of learning to be a safe doctor, don't stress about it so much. It's my justification, and I feel that it's important to know that there really is a point at which one must study and put more effort into their academics, but there is also a ceiling in regards to the 'safe doctor' concept, where beyond the proficient grasp of things that make you safe, there is little else to be gained. This is not so easy to learn though - as one eventually finds out, there are many many things that can go wrong with the human body!

This post was way too long and I'm sorry for subjecting your minds to this; so I think a summary is somewhat useful.
- Extracurricular and life priorities should not stress you out as long as you graduate as a safe doctor
- Clinical exposure and bedside teaching is one of the primary ways of learning to be a safe doctor
- Therefore treasure them; skipping on clinical opportunities to study or bludge is not the way forward.
- All this said, the clinical needs to be consolidated with relevant study, so there needs to be a balance.

And as a postscript, I am now heading to another Conference Week and then a Mental Health rotation - this may certainly be an interesting rotation!

Wednesday, April 18, 2012

The easiest rotation in the year...?

A good three months have elapsed since the last post, and I absolutely forgive every single one of you for thinking that I will run off into the night and never return to post on this blog anymore. A couple of things have to fall in place to create the wonderful occurrence that is a blog update - the first, of course, being bothered to write a blog update - given that, unlike some reflective journals in the course with a similar style to a blog, there is really no tangible reward for the blog update. Contrary to beliefs, neither are bloggers necessarily self-centred persons and so would garner their reward from simply spouting about themselves and the little intricacies of their lives - otherwise I would be posting daily - and wouldn't you love that! Heh. The second is that one needs to have time to write a blog update, and often, both the desire and the time don't necessarily correlate - in my case, this magical occurrence only happened three months after the last post. So, without further ado, should get into the meat-and-potatoes of the blog; the medicine.

In the three months that I've not posted, I've finished an entire rotation, one out of four in the year, with this particular rotation being notable for actually containing TWO rotations. Half of it is the research project as I mentioned before, the other half being oncology - the study and practice of cancers and its management. Reportedly, this was considered the most laid-back rotation out of all four in the penultimate year of the course - reflected in my style of dress during the research rotation - the hoodie became my personal uniform. As an aside, I am particularly fond of hoodies; ever practical, ever versatile, unfortunately culturally perceived as significantly more casual than a normal jacket, and thus restricting its use in certain situations. I have bought two, which is two more items of clothing I've personally bought of any other type of clothing. This also demonstrates my love for clothes shopping. It's just below ironing, another clothes-related activity which brings me great joy to delegate to my sister.

So, the group research project was in fact fairly time-consuming; the process of data collection, analysis and writing was complicated by our decision to do a qualitative research paper over quantitative. For those who don't know the difference, quantitative research involves the use of numerical findings to draw conclusions, whilst qualitative research involves methods of communication to draw conclusions, such as interviews, forums and the like. Statistical significance is a phrase that applies to quantitative research, as opposed to qualitative research where the buzzword is probably 'thematic analysis' - unearthing themes that were elicited from the participant's collective voices. So for us, qualitative research meant full days of data analysis, and significant amounts of time writing and editing the final paper. Though our group was well organised in starting the project during the summer holidays (yes, we did coursework during the holidays, voluntarily), we still submitted it on the due date, using the entire time allocated to polish the paper. We were also considering publication; but in getting into the flow of the rest of the year, that may be a challenge for us to do, juggling the requirements for publication with the standard coursework of the other rotations. We'll see how we go for that, I guess.

After the research was oncology. The most pertinent experience from this was the dying patient - of course, in medicine, you will come across death fairly frequently, significantly more than your age-matched peers. In fact, the first patient I took a history from last year died less than 24 hours after I spoke to him. Palliative care was part of the oncology rotation, and was indeed a sobering portion of the rotation. Thinking back on it, I was struck by the care, determination and love demonstrated by the patients and families, and watching the patient and family together was a privileged insight into the beauty of human relationships. This happens in the normal wards as well, but at the hospital I was at, the palliative care unit was not even physically attached to the hospital, and the atmosphere was more homely and less clinical - which served to allow families and patients to have a small degree of separation from the 'hospital' setting. It also struck me as to how important small gestures were to people. The friendly touch of comfort on the shoulder or hands was so evidently, so visibly effective, as was the act of getting a box of tissues and offering it to them. They would continue to grieve as is normal, but in the space of a few minutes, after recollecting themselves, or even in the process of grieving, they would look at you with an expression of gratitude and thankfulness. In the context of imminent death, the value of human relationships, gestures and communication become enormously amplified, and the display of compassion and empathy were hallmarks of the palliative treatment of the patient.
Palliative care also included time in clinics - not all of the time was spent in the ward. Here, we saw a number of approaches by palliative care physicians in their mannerisms, from the overtly sympathetic, to the energetic and compassionate, to the blunt but good-hearted - the last always made it evident that the intentions were for the patient's benefit. Patients responded differently to each, but it was interesting to see that the blunt but good-hearted physician had very good rapport with patients; in fact, this had a tangible effect on management when a patient revealed information to the physician that had not been unearthed by any other; this, however, occurred over a period of months. It goes to show that it is not your personality that must become that of a compassionate mother-hen, but rather that, in your own unique way, you can connect with the patient, empathise and build the relationship. I think this was a perception that I had, where I believed that there was simply one way to act around palliative care patients, that I now don't have with the exposure of multiple, effective, clinician approaches.
Oncology also included medical and radiation oncology; both were fantastic, especially radiation oncology with the amount of teaching that everyone gave us. I will gloss over it however because though there may be much to say, I've not much time left anymore!

So, easiest rotation in the year? I wouldn't necessarily say so. The complexity of research and oncology can be limitless, especially the research component, which involved both an extended period of groupwork and thus co-ordination of the team, combined with a general inexperience of research, and especially inexperience with the type of research to do, qualitative vs quantitative. There was however a one-week break between the two sub-rotations though - which was mostly consumed in my case by various other extracurricular commitments.

Currently, I've already started my second term, that of paediatrics (kids medicine)! It's my first week and I am excited to really get into it; we had a relatively unrelated conference to attend on Monday, and currently it's the school holidays so this week is a little bit odd for the special schools attachment that paediatrics includes - and it is this schools attachment that I am currently on. By far the most difficult thing I've encountered so far is actually getting down to the level of a child, and I think this is something that might face many people who do not have much experience with children. When saying things, or playing with children, sometimes thoughts race around my head such as: "am I doing it right?" and "I don't know what to do/say now" and "This feels childish" - all of these thoughts are probably stemming from the adult-child dichotomy and levels of thinking, and most likely also my own stupid propensity to think and write using words like 'dichotomy' and 'propensity'. I don't even know what they mean, I'm just writing it to sound smarter. But seriously, it is challenging, and one of the teachers has called it 'daunting' - I absolutely agree, not just with children with special needs, but children in general. I had even gone so far as to see if there were any papers on building rapport with children (which there are by the way, there are papers on everything) and asking parents what they do with children. Anyway, I'm fairly sure this will fade with experience with children, and I've hoped that my exposure with my nieces/nephews (ranging from 2-8yo) will help somewhat. But in no way do I feel ready to be a parent, haha - I personally think that's one of the hardest jobs in the world, full respect to parents juggling parenthood with everything else going on at the same time.

Tuesday, January 31, 2012

Seniority

Well, the 4th years at UWS have just started and we're on our second day of Conference Week 4 (continuing on from the three conference weeks in year 3). It's been a pretty hectic couple of days, and...

...oh, yeah, by the way sorry for not posting for 4 months, haha... I've been pretty busy during the holidays with all sorts of extracurricular as well as a family holiday, and now that I'm back it's going to be even busier than ever. 4th Year sounds deceptively easy because everyone makes a big deal of the fact that there are no end of year exams this year - but, thankfully, there's our massive barrier exam in the middle of 5th year, OSCEs at the end of each term, miscellaneous internet-based projects to complete, the end of year elective to plan, and the hefty schedules during some of the most intense terms during the course (paediatrics and obstetrics&gynaecology).

I therefore don't have much time to post, but nonetheless will try to post as regularly as I have in the past (admittedly not that regularly) - so once every month or so. I'm still astounded that this is around and will do my best to see this through the years.

Anyway, congratulations once again to the new UWS meddies! I hope you enjoy your first year and take advantage of all there is at UWS, not just academically but extracurricular as well. I feel that the university experience, especially in first year, is about developing academic curiosity, learning how to learn the university style, and making the most of your time with a group of fantastic like-minded people who are all smart and driven. First year is a relative cakewalk if you can adjust well to university-style studying, but also is a good opportunity to get some solid foundations down and explore avenues you may not have otherwise considered. Also, you may see me pop up at one of your first lectures!

I'll be back with more substantial stuff later on, I'm starting off with a group research project which we're quite excited to be working on (and hopefully publishing), which has been going quite well and is in an area I didn't really quite expect to be interested in - and also a research-void area of interest as well! So until later,