Another rotation flies by

Back after a month, and this time I've finished my Endocrinology/Geriatrics rotation, with the exception of a one week stint doing rehabilitation medicine in a linked hospital. The term was extremely busy compared to Cardiology - we had about three times the patient load of my old cardiology team; but somehow, we managed to have more coffee breaks! I never really quite got my head around that one. The rotation was essentially a geriatric one, with endocrinology clinics featuring some interesting cases of thyroid problems, acromegaly and carcinoid syndrome (!) which are quite rare cases indeed, and it was wonderful to meet these patients first-hand, who had a real can-do, positive attitude about managing their disease. Strangely enough, the team was also burdened with a rheumatology aside, which was all but inconspicuous to me until the very last day when I saw my first case of scleroderma.

This term was punctuated by AMSA Convention!!

AMSA Convention was at Sydney this year, and seeing as I really don't expect to have the time, energy or money to bother flying out to any conference/convention in the future, I thought it best that I attend it whilst it was at least here in my own harbour. I must say, it was brilliant - inspiring and engaging speakers from all sorts of backgrounds - working with the UN, Discovery Channel, media personalities, and authors from around the world. It is interesting to see where some doctors go after they finish their training, and thought-provoking (at least, for me) in considering the path we could choose when we would be done with ours. The afternoon workshops were also excellent, including the renowned Talley and O'Connor duo (who I fear must have been sick of medical students lining up to take their photo, impeding a quick exit from the lectern hall) and controversial neurosurgeon Dr Charlie Teo. The topics of discussion were at once filled with humour, reflection and practices within medicine, and it was certainly well worth the attendance. Finally, the inter-uni debating series organised at Convention were a great source of amusement, in particular the UNSW vs USyd match, which I felt fitting to have in the lectern hall given the sizeable rivalry displayed at the debate. Unfortunately, I only attended two days (no nights - wasn't feeling up to the night-time mischief that goes on whilst knowing I had to be back at hospital the next day), and so was not able to attend the Emergency Medicine Challenge or the other talks - but from what I heard, they were excellent as well. So, definitely a worthwhile experience - if you can, make a point to attend AMSA at least once during your course - and if you've been to AMSA Con before, I'm sure you'll back me up :)

Going back to the rotation business, I thought it pertinent to bring up an issue very commonly seen in geriatrics - the Advance Care Directive (ACD) and Not-For-Resuscitation documentation. For those who are unaware, this is essentially the decision of the capable patient, or if not possible, the next of kin, in regards to how much the hospital should intervene in the event of an arrest or decline in function. The two forms are not identical, as the ACD is more general and comprehensive, but both deal with making sure that what happens to the patient is what the patient wants.

The cynical observer may put forward the idea that ACDs save hospitals money and time, as sustain life artificially is an expensive and arduous task, as well as occupying a bed in Intensive Care Unit. However, as one may have realised already, ACDs are a way of ensuring that we deliver the best possible care to patients. At what point does intervention so reduce the quality of life that it is, in fact, causing the patient harm? There is no set-in-stone regulation answer to this question, and it depends on the patient's mentality and wishes. Thus, there is no better way to make sure that the patient and family are satisfied than to arrange plans for the time when there is no time to plan. The ACD also gives a good idea as to what is offered by the hospital, as most patients, upon entering the hospital system, have very little idea as to what happens within the system and what can be done in their case. Finally, I believe that bringing up the ACD and NFR status of the patient stimulates discussion of death and dying, good and bad ways of dying, and how this may affect the family. Since mortality in this life is 100%, we can only really control how we die - and medical treatment can help determine when we die, but not whether we die (at least, not at the moment or in the foreseeable future). Through observing the process of resuscitation, intubation, insertion of various lines and admission into Intensive Care Unit, it makes sense to me why many doctors in geriatric medicine tend to recommend NFR status and withholding of various invasive treatments, and the majority of patients and their families come to understand this as the most humane treatment of the patient.

It's the opposite of what many imagine a doctor to be - a life saver, a guardian standing between life and death, etc etc. The heroics are newsworthy, but the genuine compassion and care that occurs every day within the hospital and outside is far more important in affecting the population that come through the doors of hospitals. It's triggered an internal conflict, as I had found myself leaning towards Emergency Medicine for the patient variety, all-encompassing nature, and opportunity to impact the patient's initial management the most - but the most impressive work seems to be hidden away from that hustle and bustle, and I am definitely most impressed.

The starting gun is loaded

I'm now only 6 days away from heading into third year, and am definitely excited about what's coming up ahead! Bought Oxford Handbook of Clinical Medicine (OHCM) after finding it at the cheapest place possible (on Abebooks.com for $33) and am voraciously reading it whilst waiting for mum to finish grocery shopping. The only downside of getting your P's (driving licence) for me was suddenly becoming my mum's chauffeur, and considering it's the holidays, she believes my main priority is to make up for the past 10 months of not contributing to the house - i.e. driving her around. So OHCM is my way to whittle away the wait... also got an ipod shuffle for Christmas, which I've loaded some New England Journal of Medicine (NEJM) audio summaries on for some bedtime listening (or alternatively whilst jogging).

Turns out that that was pretty much the extent of my study this holidays. I finished reading a book on clinical decision making, but only because it was interesting and only a couple of hundred pages; borrowed a few other books and haven't really made much headway. So I guess I've had a pretty relaxed holiday, which is good - considering how rare holidays are going to become. Took up some more exercising, as well as piano (after practicing for a month, I still can't quite get the Pirates of the Caribbean theme 100% correct yet), which I've neglected for a long time - presumably, due to studies (...not really).

I probably haven't discussed third year in much detail before, so I'll just give a little bit of a rundown as to what I'll be spending 90% of my waking hours on this year (psh, actually more like 50%, need to account for time spent doing very unrelated-to-med things). The year is essentially split into three 'semesters', which are each split furthermore into halves (hence, six 'terms'). The semesters are known as Medicine in Context, Medicine, and Surgery.

Medicine and Surgery are pretty self-explanatory; they are both hospital-based, and as you would expect, in Medicine you would be joining a medical team (e.g. gastroenterology, neurology, geriatrics, other fields of medicine besides surgery or general practice) and expected to both learn and pull your weight as part of the team; whilst in Surgery, you would be joining a surgical team (in third-year, this is mainly general surgery, but depending on what you were allocated, you may be joining a vascular, maxillofacial, orthopedics or other more specialised teams in addition to general surgery) and expected to be on time to scrub in (get ready for the surgery by taking surgical sterilisation precautions) and to learn.

Medicine in Context, which is the semester I'll be doing first (in order to spread out resources evenly, a third of students will be starting with MiC, a third with Med, a third with Surgery, and then rotate), the week is divided into a one-day-a-week General Practice (GP) attachment, a three-day-a-week Community Organisation attachment, and a "reflective/presentation" day (Fridays) which seems to be either a go-back-to-campus day or "free" (read: they want you to study) day. In regards to the Community Organisation, this is an organisation which deals with the related elective or subject that you have been allocated (although I say allocations, you are given a preferences list to fill out), which for me will be Disability and Mental Health, my first and second terms respectively. Each term is six weeks in length, and each semester begins with a conference week, which as mentioned before, is essentially a week filled with lectures.

The GP I'm going to be attached to is very close to my house (about 3-4km) so I'll be looking to cycle there and back; my Disability organisation is also fairly close (about 8km) so that might be possible to cycle there as well. This is probably one of the big changes between pre-clinical (first and second years) and clinical years for me, as the return trip has literally dropped by >80% from 3 hours to 30 minutes - which is nothing to sneeze at. However, an equally big change is going to be the largely reduced amount of time with the rest of my cohort, as conference week is the only scheduled time for the whole cohort to meet; half of the cohort is in the south-west whilst the other is in the west/north-west; and a third of the cohort will be not in hospital the majority of the time (the third that will be doing the Medicine in Context rotation). Also, I don't get much time to get to know the Malaysian students, since they'll be at Campbelltown whilst I'll be an hour-and-a-half's commute away - which is kind of sad; in addition to the people from my cohort last year who won't be in my cohort this year (Medical Research degree, deferring, repeating). On the upside, I'll be spending a lot of time with a few people, which hopefully means I'll get to know them a lot better - my main partner for this year I barely know, so there'll be plenty to cover in the downtime.

So, it's time to ring up my allocated organisations, get ready those notebooks and prep my bag for what should be a very interesting year! As always, I'll try my best to keep posting during the year - still amazed that it's still here after two years, my longest blog effort ever haha...

Hospitals are not cheery places.

I keep hearing that ICM (Introduction to Clinical Medicine, or hospital visits) are the best part of *insert students name here*'s Medicine experience. While I think it certainly is necessary and is useful to build up communication and clinical skills (later on), I don't always agree that ICMs are the best part. Today was a rather shell-shocking day; an elderly man was gaunt and straining to exhale due to progressed emphysema, hard of hearing and generally in a poor state. In the next few minutes of our interview we were introduced to his life as a result of decades of smoking. It's not like we aren't aware of the dangers of smoking, or the possible consequences and risks; but more the fact that it confronted us here, right then and now when we were just expecting to practice our history-taking and interview skills. His condition was such that he could not work, mow the lawn, do most housework, and look after his wife; confined to sedentary activity and struggling with every breath, he remarked that he felt suicidal. When he said that, we were all stunned; 6 first year medical students meeting a man in whom hope did not exist and despair reigned. And this reminded me of what we were here to do, but also, it reminded me of what we couldn't do; when all we can do is really give painkillers and pretty much pray for a painless death. In PBLs and other ICM interviews we have encountered a few chronic diseases, and its nice to be a doctor and be able to make someone get better, but with specialities like Pallative Care I wonder how they get through every day intact. Our patient re-iterated "don't smoke" and its a fair warning, considering his personal testimony, and all I can think of is how he hopes to stop others from going through what he is right now. Whilst cases generally make me motivated to study harder (in light of an application for that knowledge later on), this one just hit me and hasn't had any positive effect so far, except for this reflection. Much food for thought.

Mid-Year Exams

So our mid-year exam timetables were released today.
And as of today, I have exactly 1 month and 5 days to both catch up on everything I've done previously, and keep up to date with the next 4 PBL cases, including this one. Looks like I've got to buckle up a bit and stop major procrastination.
I was actually fairly excited about exam timetables, because I felt pretty ok about my position in terms of lectures and PBL cases; but the fact that it is barely over a month away has really hammered into my mind right now, and it's kind of frightening. We haven't received our Formative Test results back yet, so I'm not sure how much I already know and thus how far the bridge is between simply keeping up, and starting to put in maximum effort from today. It's annoying that I know I will inevitably lose an hour or two PER DAY to gaming, or MSN, or facebook, or some random crap that isn't at all related to my future - but hopefully I'll still remain productive.
These medicine exams feel a little different to high school exams; I know that this forms my education towards a career, and most especially, towards dealing with patients, instead of a competitive Maths test or English speech, working towards a number. All the same, i think a little bit of healthy competition is strengthening me; I've found a really smart colleague (our PBL tutor called us this; colleagues. I was amused, as was everyone else) who is keeping on top of things, so my aim, childish as it is, is to do better than him. I know that if I do, I've kept on top of things; but even if I don't, I've done my best for the best cause I can possibly think of at this stage: my own life.

Laziness

Even though most of the content in Medicine is really interesting, there are times, like today, where I can't seem to do any work. And it annoys me because I'm trying to read a textbook or something productive, but I don't concentrate because I'm not in the studying zone. Or a gaming zone. Or anything-at-all zone, really; it feels like a do-nothing-cause-I-can't-do-anything-else day. All the while it's paining me that I could be using this time to work towards something, anything.
*yawn*
I also tutor high school students in my subject of interest, Software (SDD), for HSC. To be frank, tutoring has nil impact on my study situation at the moment (which I think is ok compared to my HSC, but still dismal), and I tutor... 7 hours a week. So it seems like its more than doable to hold a job whilst studying Medicine.

I'd like to comment on Medicine's workload so far - and it's lived up to the expectations in terms of the amount of content covered, but also the relative ease of the content, versus some really brain-boggling stuff my friends are dealing with in Law, Computer Science and Engineering. The exception to this is probably the huge mechanisms for things like the Kreb's Cycle (google or wiki for the goodness of this 8-step cycle taking place in the mitochondria of a cell) and the biochemistry; and perhaps some pharmacology, but the rest is pretty easy to digest. It's also possible, at the moment, to only do 4-5 hours of week per week and still manage to get by, by simply using the time at university productively (I'm doing about an hour a day, which is pretty low methinks - aiming to obviously ramp it up a bit). I'm certain both the difficulty and quantity of Medicine would increase, mainly the latter. It's all just a matter of keeping up with the program though, and you're in no danger of having no time for a social life in your med student years. The future, however, is a little less uncertain...

So how do I begin...

My previous blogs have all fallen in a state of disrepair, forgotten and alone in the little corners of the vast cyberspace. So here I go, restarting afresh, anew, and hoping this will not end up disused.

A little introduction is necessary: My name's Luke, and I'm a medical student at the University of Western Sydney (UWS). I, if not undertaking the Bachelor of Medical Research or repeating a year, will graduate in 2013, as the MBBS degree at UWS is 5 years in length. I decided to start this blog on a spur-of-the-moment, hopefully sharing my experience as a medical student here in Australia. To understand where my opinion henceforth is based upon, heres a little of my background:

~ I'm of Chinese descent, though my parents were born in Malaysia and I was born very locally (Westmead Hospital in Sydney, NSW, Australia) and raised my whole life in Australia. As such, I consider myself pretty Australian, though I am pretty hopeless at sports, contrary to the stereotype. I come from a low-middle class background, and I'm the first of my immediate family to go to university.

~ I entered medical school in Australia by a rather typified method: through OC Class, Selective School, HSC marks, UMAT, and an interview. I entered med school straight out of high school, and though there are reasons not to do so, I don't regret it at all.

~ Culturally, the pressure to achieve academically, for me, was fairly high, which is probably not unlike most medical students in Australia. However I procrastinated a lot, also not unlike most medical students in Australia; so it's kind of ironic to enter a career where maintaining academic effort is of extremely vital importance.

~ I consider myself EXTREMELY blessed to have entered medical school in my first attempt, straight from high school. My procrastination was the bane of my parents and as a result I did not score a 99, or even 98+ UAI (seen by many as a given for medicine in Australia), I was a Greater Western Sydney student and thus had local advantages given by UWS to encourage local students, I was only offered my spot in the Late Round of UAC Offers (University entrance offers), and it was a Bonded spot (requires a contractual obligation to spend 5 years after specialisation, working in a District of Workplace Shortage - i.e. where there are not enough doctors of your speciality). So I guess this can give some of you hope in regards to medical school entry.

~ I was and still am really keen on Medicine. Along with the altruistic nature of the profession, Medicine ticked my boxes because it was a secure job with a decent pay, was extremely broad and yet you could find a speciality that could occupy your entire life, was one of the few occupations where there is continuous learning and expansion of your knowledge, made my parents quite happy, was a field where I had an interest in (my other interest is Computer Science), and allowed the undertaking of responsibility of lives but also the privilege of being able to treat patients and play a significant role in their lives. In exchange, I considered the rather long hours, lengthy time to finish training and specialising in comparison to other courses, high stress and emotional situations, and a huge amount of (expected) study for the rest of my life, but they didn't deter my decision. It is important to see whether another career/degree suits you better, although in my case I'm overwhelmingly happy with my decision. This will hopefully not change as I progress through the registrar years, and I hope not to become a disillusioned junior doc in the future.

~ I keep an open mind towards anything and everything, including country practice, all types of specialities, conference attendance, anything. So I will hopefully cover a large spectrum of the medical student experience in Australia and in particular my university.

That's probably enough introductory information to show where I''m coming from, so I'll leave it at that. I hope this blog will have two purposes: firstly, to share what I have gathered through personal research and communication, and secondly as something to look back on when I am old and grey. So thank you for dropping by!