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.

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.