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!