Erm... that's Dr TTBAMS, actually...

It's true, I have finally done it. Dr TTBAMS at your service.

After five long years of medicine and two years of "extra", I have at last passed everything and am legally permitted to call myself doctor. Oh, and look after patients, under supervision.

People keep asking what I've done to celebrate, and although fizz bottles were waved around (my sister and I shared a tiny bottle of pink cava on a bus, and the other half produced a bottle of proper fizz and a bottle of French kids' fizz, which is the lovely non-alcoholic fruit juice version, wish they sold it here) I have done very little. I don't feel particularly celebratory - my main response was "well thank goodness for that". At least I don't have to go through that ordeal again. "That ordeal" can be either final year or the entirety of medschool, depending on how exhausted I'm feeling at the time.

Honestly, I am just so glad it's over. I have been thanking the friends who got me through that last exam, and the other half for getting me through the whole thing, but I haven't really reflected on my achievements. One day, when I recovered from the relief enough to actually think about it, but not yet.

Maybe that's partly because the celebration is tinged with trepidation and nerves in the "OMG now I actually have to go and be a doctor and have responsibility for people" kind of way but I haven't been dwelling on that. I think gynaecology is a good place to start - there aren't too many life threatening mistakes that a junior can make. Don't miss an ectopic pregnancy (then someone actually could die and it be my fault), and if there's any risk that anyone has a lady-cancer, get a senior to check them out. I think starting in Accident & Emergency (or the Emergency Department, depending on the hospital) would be a lot more scary.

And so, non-existent reader, you may be wondering what's next for this blog - clearly the title doesn't fit any more. You can't try to be a medical student if you're already a a doctor. Or you'd be a bit odd if you did. I have it all planned, I will be moving to pastures new, or basically nextdoor, to www.tryingtobeajuniordoctor.blogspot.co.uk when the time comes that I actually am a junior doctor (i.e. next week). Please do join me there, and don't join me in my hospital, at least not in August - being ill in August is statistically not good for you*.

* I intend to find a reference for this at some point! In the meantime, don't test my claim!

Leaving the wrong job....?

For the last 5 years, I have had a vacation job during university holidays: I work in a museum. Not the small stuffy kind, the large, over a million visitors a year, amazing site, kind. It's had minor ups and downs over the lsat five years, but overall I have totally enjoyed it. I've been very lucky.

 This is not my museum! But it is a good one. Thanks to http://www.nyeparry.com/?page_id=619 for the picture.

I went back to work there recently after many months away (final exams) and was struck by a number of positives in this job which don't exist in medicine. I should have blogged about it at the time, but perhaps writing now will jog my thinking.

I love how in this job there is a team spirit, sometimes it's us against the world/tourists/tour group leaders/supervisors/powers that be, and that can unite a team, and sometimes it's us generally putting effort into ensuring that tourists and customers have a memorable few hours at our site, together. As a student it's difficult to really be "involved" in any hospital team, but none of the teams I've had anything to do with have had a team spirit that I could sense from my position as a student at the edge of the team.

One thing that particularly struck me is the culture of respect. It's a big group of people so of course some people grate on others a little, but even so there is a sense that the staff respect each other. In particular, people respect the supervisors, but not just because they're supervisors, but because a) they're (mostly) good at their supervising, b) are nice people, and c) they respect us. In medicine it sometimes feels like the seniors are respected because they demand respect, not because they deserve it. It creates a very different culture. It's not a big deal, and it's only noticeable when you start to think about it, or when you've been working elsewhere that doesn't have such a culture.

Recently in the museum a slight change in the system was trialled, and the supervisor asked my group of assistants for our thoughts and feedback - the senior staff genuinely want to know what the "junior" staff, the people actually implementing the changes, think about it, and will take those comments on board. It's not often that I've seen seniors in medicine asking for juniors' thoughts and feedback, except in a grilling and knowledge-testing sense.

Even at the busiest and most stressful times, people are generally happy and still so willing to help each other out. Again, not always evident in medicine. But maybe the stress is different - in the museum stressful times means long queues, angry customers, obnoxious tour group leaders etc. In medicine stressful times can mean the weight of the responsibility for patient's lives, especially when the line between a patient living or dying starts to thin. Perhaps the difference is stress contexts explains the differences in atmosphere here.


A colleague, for whom this is also "just" a vacation job, asked me today if I don't find this job a bit menial, since I have a good degree and will be a highly qualified professional (clearly indicating he finds it menial for this reason). I first told him he needed a slap, then pointed out I have two good degrees! Just because I'll be a qualified professional, in a totally different area to this job, doesn't mean this job is beneath me. It has taught me a great many skills, such as: communicating across language barriers and cultural barriers, communicating with children, diplomacy and tact in customer service, particularly with difficult customers (which transfers to diplomacy and tact in dealing with patients, particularly "difficult patients"), conveying complicated information in a way the recipient will understand, and the ever-useful skills of voice projection and crowd control. None of these are medical skills, but all of them are likely to be useful during my medical career. That's not something to sniff at.
There is the additional benefit that this role has enabled me to be competent and above all, confident, in dealing with many, many people, and confidence is not something one can acquire overnight, or just by magic or good intentions. The confidence I've gained from putting effort into this job, and knowing from the responses from colleagues and customers that I'm doing it well and making a small diference to someone's day, is something I couldn't have gained simply from being a medical student. A medical student I've found is frequently too much of a fifth wheel to have much of a sense of achievement (that's not to say that achievements aren't made, but just not on the same level).


Now the terrible bit is that I realised recently how much I enjoy this job, and how many of the things are appreciate are not present in medicine. I could only wonder why I'm leaving a job I've enjoyed, for one that predominantly scares me, in an environment which I don't always enjoy or feel respected or comfortable in. It feels a little bit mad.

Perhaps part of the reason I've enjoyed the job is because I know I won't be doing it forever, and perhaps if I were I would have a different approach to it. But I hadn't really thought about the fact that I would one day be leaving this job, in order to take up my forever-job, (the one I've been studying seven year for) but now it's suddenly here, and I'm leaving tomorrow. I'm really not sure if I want to!

I can at least be thankful that I've had employment which I enjoy, to return to every holiday (and some weekends), in a group where I feel part of the team even if I've been away for months, and have been able to go through my education with far more financial security than I otherwise would have.

After all, if medicine all goes pear-shaped, I might always have a nice job to return to! I could be a museum-doctor.

First, I have to get through, and make the most of, my last day tomorrow. It feels like the end of an era, and it feels silly to leave a job I like*. Needs must....

(*It was suggested to me that I'd have enough holiday from my doctor-job to return to my museum job occasionally, but 1. I do quite like the idea of having a holiday which is entirely a holiday, no job or revision or essay-writing to have to do, and 2. most importantly, I couldn't justify it. I'd be on a nice NHS salary, taking part-time holiday work away from school leavers, students and other people who really need the money, when I really won't - that's not right, and I wouldn't have particularly wanted someone earning good money to take my shifts away from me the last few years, when I've needed the money.)

Carer's holiday, and a holiday for the carers

As I discussed extensively with Steph at Steph's two girls, I have a sister with Asperger syndrome (an autistic spectrum disorder). This week we went on holiday together. It was the first time she'd been away without our parents, so while it was a welcome break for them, it was a bit of an adventure for her.

My mother was convinced we would come back not speaking to each other, but we were even still laughing with each other.

However, I've come back with a newfound respect for people who can organise and take responsibility for a holiday and for other people's needs, when the other people can't communicate those needs. Taking care of meeting someone's needs without knowing what the exact needs are at that time and place is a skill I haven't yet perfected.

I've also come back with a newfound understanding of the little difficulties in coping that, when added together, make an independent life currently impossible. And a wonder about how outsiders, such as the lovely people at ATOS who will assess her disability living allowance, can possibly notice or understand such minutiae, and comprehend how someone who at first seems competent if a bit odd, actually requires extensive support.

But we survived, and had a lovely (if exhausting) time. Would we do it again? Yes, but preferably with better communication on what each person's preferances, needs, and limitations are, with updates when they change. That would be the life...

And also ideally with a sense that all the independence training that the holiday involved was in some way wanted or appreciated. It's difficult to have no idea but feel the need to pursue the ideas of independence and gaining skills anyway.

But yes, we would do it again.

I get by with a little help...

...from my friends, and other medical students who I don't even know that well.

The burnout that I mentioned has really been affecting my ability to work. I'd got books out from the library, from which to re-learn everything I knew in January, and hardly opened them. When I did open them (following an extensive internal battle to make myself do some work), I either struggled to concentrate or just fell asleep. I needed to leech off other people's energy to get things done, as I didn't have any left of my own.

A few lovely friends had offered to help; I found this really useful. There was no internal battle to work, as I'd met with them specifically to work, so I had to do it, and they wanted me to. A friend played the patient and either invented a history or tookone from a book (book review coming soon!) while I played the doctor and took a full history, with OSCE-style strict time limits. Friends in my year who had passed everything gave advice on how I needed to improve my performance. I also practised examinations, such as orthopaedic joint examinations, again to time limits.

This was so helpful and avoided me having to motivate myself (unsuccessfully); I realised I needed more of this. But three friends couldn't provide the help between them, and I'd feel bad taking up so much of their time.

I posted a status on facebook asking if anyone could help over the weekend, and had conversation with a friend offering me advice, but nothing more. Eventually I realised that motivating myself was getting nowhere, and although having three friends to help was wonderful, it wouldn't see me through the exam. So I sent a facebook message to 16 other people, students in my year and the year below, good friends and less good friends. I explained my burnout and need for people to help, what I needed (extensive surgical knowledge not required!) and the times that I needed help. Within 24 hours I had seven wonderful replies, all encouraging and movtivating me, and each offering different times that they were free to help.

Just reading those replies made me feel that this huge task might be possible, that maybe there was a chance I could face this big exam with confidence, and succeed. All except one stuck to their word and came to help (the one who didn't, didn't live near and we hadn't made as concrete a plan), all for over an hour.

For a whole week I did no work on my own, and felt very little guilt about it, because I'd worked with nine different people, and the quality of the practice was so much better than anything I could do alone. Quality over quantity, number of hours less important.

I had a little further help the next week, to ensure that I maintained my history taking skills, which had improved greatly, becoming slick and fluent. I there had some confidence going into the exam, I  knew that I could do it because I'd done it many times before. There is nothing like preparation to grow confidence.

Failure lies not in falling down, but in not getting back up again. For me to get back up, I needed help. There is no shame in needing help, the failure is in not seeking help. Asking a whole bunch of people to help me was one of the best things I've ever done. If only I'd recognised the neeed and could have asked for it earlier. Oh, hindsight.

If you need help, ask, and keep asking. Ask for specifics - I told everyone what I needed, and when, in timeslots for people to choose (e.g. "I need Thursday evening, Friday morning and evening" etc). It was easy for people to help because they knew what I needed.

In paediatrics people sometimes talk of "the team around the child" (or the team around the family). I've had so much support the last two weeks it felt like the team around the [TTBAMS].

If I have passed, it will be thanks to all these lovely people, and because I asked for help.

That's "me" in the middle of the team huddle - having that much support feels amazing. (Thanks to the Nigerian football team for the picture)

Ideas, Concerns and Expectations, Baby

I've seen this wonderful video/song via Wishful Thinking in Medical Education, about asking ideas, concerns and expectations (ICE) of a patient in an exam. It often seems contrived, and though this video is about exams for general pracctice trainees, it's so true for medical school finals too. It's definitely on my mind given the final OSCE in a few days, though I find myself running out of time before asking it.

Also, I've been told the real skill is not about whether you ask ICE, but how you respond to it.



I would love to know the guys that put this together... they must have more interesting characters than some GPs I know!

This is what an anti-rape and anti-sexual abuse campaign looks like

via Khale at http://misspixnmix.tumblr.com whose wonderful "I do not have an eating disorder" comic I've mentioned previously.

This is an anti-rape campaign that places no blame, and no responsibility (except on the perpetrator), but encourages bystander intervention. It is amazing. Men Can Stop Rape, an American organisation, also seem amazing.

Did I mention I'm a feminist? It shouldn't come as any great surprise, as I hope this blog has so far made clear that I'm no doormat. TTBAMS is what a feminist looks like.

                        "I only know that people call me a feminist whenever I express                        sentiments that differentiate me from a doormat"

                                                                                        - Rebecca West 



Before anyone thinks, I do know full well that this kind of campaign does not prevent every rape or sexual assault or abuse. But maybe it makes a difference, starfish-wise.

Anonymous

I knew from the beginning that if I were to write a blog that included my experiences of medicine, and possibly some of my experiences with patients, it would need to be anonymous. I've mentioned this briefly before but it does need a post of its own to explain this.

Posts like this one, and one in my head about a patient I saw die, seem to require anonymity to protect the patient's identity as well as my own. Of course I do everything I can to protect the patient's identity anyway (changing identifiers etc), so that even the patient themself wouldn't necessarily recognise themself in my blog. But it's easier to ensure nobody recognises the patient if they don't already know which hospital, city or even area of the country the patient was seen in, or which medical student or doctor they saw.

There's also the issue that I don't particularly want my future patients to read this and know that it's their doctor, looking after them, who wrote it*. They could easily lose faith in me or not want me to be their doctor. It's not that I'm lying to them, but my doctor-face that I present professionally is confident and professional, and different to my blog-face and the things I share on here - my fears and failings, along with some potentially more contraversial thoughts.

I talked to a (non-medical) friend recently, and told them I had to re-take an exam and only narrowly passed a few others; their response was "I'm glad you're not my doctor" - I can see why. But once I have passed, I am deemed safe and competent enough to practice, and I'm no different to any other doctor. I hope my patients would see that, but some wouldn't and there's no need to tell them all and make an issue out of it.

I don't necessarily want all my colleagues to know that this is me, I don't want my consultants to know my fears and failings - if I did, I could tell them.

My posts about my medical school have sometimes been far from positive, but I don't want to bring them a bad reputation, just because I blog negatively about this medical school and people may not about others. And you never know, they could pull me up on things I've posted - it wouldn't be the first time a student had been reprimanded for things they'd put on the internet.

Since my posts about my family aren't always complimentary, I don't want them to see this blog and know that it's me, either.

If this blog weren't anonymous, I'd need to censor it and be more careful of what I wrote and how it could come back to bite me in the future.

I'm aware that other medical students don't always blog anonymously. The medstudent in the link implies that being proud of what she writes is part of why she doesn't blog anonymously. That's not to say I'm not proud of what I've written, I am to some extent (the mopey and despairing posts, less so), but I think the reasons for anonymity far outweigh the reasons against.

I hope that doesn't make me a coward - I don't think it does, but I'm sure it could be suggested.


If you know me personally and want to share this blog, feel free to but I'd prefer it if you don't blow my cover. Please do share it, it would be nice to have more people read it, but please don't share it in connection with my name or identifiers. This post has been a long time coming, and it's because of this bit that I haven't really felt able to share this blog with people I know until know. Apologies to people I know who've come here, you've got 34 posts to get through if you want to read this blog!

*If you don't know me, and you've read this, would you want me looking after you? Really?

Like a little piece of charcoal

I woke up on Monday with so much dread for the week ahead and the work required that it suddenly came to as I was lying in bed: I am burnt out. On the one hand, that's horrible and means that I have no energy to do any work at all. But on the other hand, it's greatly relieving. It means I'm not lazy and useless, it's not all my fault that I haven't done enough work, it's just that I've done so much work and been so stressed for the exams in January and May that I just don't have enough energy left to keep going.

It felt so good to put a name on how horrendous I've been feeling about this exam and having to work for it. Burnout is a recognised concept, and a friend of mine had it after the January exams. I contacted her on Monday and she gave me some advice, including: get away from everything, go for a run even if you don't like running (which I did, briefly), burnout usually means you've done enough work already (yes, I did enough work in May, but unfortunately not for this re-take), to go easy on yourself (definitely), and to make a list of all your achievements, to push you on through this last one. I like that list of achievements idea - I haven't done it, but I have been thinking a little more about good things I've done, and that this re-take is really just to put the cherry on the cake. Except you can't have the cake without the cherry on, it is essential.

I realised that if I don't have enough energy to keep working through this revision period to the exam (which I don't), then the solution is to use other people's energy. Leech off them to get me through it, and work with others.

Which is what I've been doing. The only self-directed work I've done alone all week is to listen to a few podcasts whilst out walking places. So far, so good. Boo for burnout, but massive hooray for recognising it and getting through it.

Breaking the stereotype?

At the medical school's graduation ball last night, for medical students/soon to be doctors and their guests, and some faculty, most of whom are doctors, there were some speeches and presentations made. By far the biggest applause of the night, with a standing ovation from the whole room (about 170 people), and two giant bouquets of flowers, were not for any doctors at all, but for two nurses.

Two nurses who were both previously intensive care nurses and are now clinical skills facilitators, and teach us so much of what we need to know, and if any of us save the life of someone who's seriously ill in August, it will be thanks to them. In fact for many of us, passing all the exams and becoming doctors at all is thanks to them. Especially for us re-takers, as one of the two nurses oversees the re-take program and eggs us on through this tough few weeks.

They completely deserved their applause and flowers and all our thanks, and it made me think because doctors and nurses don't traditionally have the best relationship, and sadly the culture is still one were some doctors look down their noses at nurses, but last night there were over 100 new doctors with more gratitude and respect for two nurses than they've ever had for any doctors.

Hopefully we'll take that gratitude and respect with us into our many different hospital workplaces, and whenever we meet and work with other nurses, and particularly if we're frustrated or challenged by them, we'll remember the gratitude and respect we had for the two nurses who got us there.

The (hopeful) graduation ball...

Last night was the graduation ball. The re-take is in two weeks, so I don't yet know if I'm graduating. I remain fairly convinced I won't be - I've bought the guest tickets and am wondering about what to wear, but all in a "just in case the unimaginable happens and I am actually supposed to be there" kind of way, not in a way that I expect to be there at all.

I'd originally decided that I wouldn't go to this ball for this reason, but friends persuaded me, and I did half want to go, especially since I was so gutted that for my original graduation ball - the one I would have gone to had I not intercalated for my BSc for a year and then taken a year out - my friends forgot to (or decided not to) tell me about it or invite me. The photos of every single one of my original medical school friends at the ball without me were a little tough to see.
Anyway, I decided to go. My main trepidations were that it would take time away from revising and would be difficult to go to before having finished exams. I didn't pay attention to the idea that at the grad ball everyone else would know they were graduating, and I wouldn't. Well, about four other people there don't yet know, but since there were over 170 in attendance...

Going to the grad ball before knowing I'm graduating was very very odd. Much as the other half kept reminding me that I had as much right to be there as anybody else, it didn't feel like it at all. I felt like a spectator rather than a participant.

The worst was walking in to the dining room in the fancy hotel to take our seats for dinner. All the place names said Dr so-and-so for everyone graduating. That was hard. There was one at my table place saying Dr TTBAMS, which on the one hand is lovely because it means the guys who made them believe I'll pass, but on the other hand it's bloody horrible because I am not yet Dr TTBAMS. It all got a bit too much for me... I couldn't really hold it together and started crying. Everyone at the next table were taking group photos with everyone holding their little Dr place name, which made it worse. Thank goodness for waterproof make-up (yes me, in make-up), and for dinner jackets requiring a silk hanky in the pocket (or maybe it's just that other half does these things properly - it did match his bow tie). Thank goodness also that our table was in the corner, and that no one else had yet arrived at the table - my friends were pushing fashionably late to the limit. Thank goodness also for the wonderful other half, who reassured me that I do deserve the place name, but tactfully turned it away and moved it out of my view for the rest of the evening.
I regained my composure, but it wasn't the best way to start the night. I don't think I was great company all night really, conversation dried up where it wouldn't usually.

In retrospect I should have given a little more thought to the difficulties I might encounter during the evening, other than my bad my nail varnish skills were. And I should have approached it with dignity in mind. I think focusing on celebrating other people's achievements, rather than dwelling on my own lack thereof, might have helped.

Friends have said we'll have a celebratory get together, with the sweets (goody bags), glowsticks and lottery scratchcards from last night, but I don't know if it will happen as I get my results after term is over and people will have gone on holiday.

In conclusion: it wasn't a great night. But I don't regret going, really, I regret not being better emotionally prepared. If I hadn't gone, I would have regretted it.

Other half told me last night he's saved my place name, ready for when I am Dr TTBAMS. I'll have a party all of my own when the time comes. Whenever that may be...

I keep my visions to myself

Guess the song lyrics title at the bottom....

The night before last I dreamt that I'd found a patient, a rather mad lady who clearly needed some help, just outside a hospital (that looked a bit like Berlin Tegel airport somehow), but I couldn't get any phone signal to call an ambulance. So I had to take the patient into a hospital waiting room while I got some help, and I couldn't find any. I was upset that I couldn't help her. Somehow much later on someone pointed out that I could take her to Accident & Emergency, and I was so relieved, but also very worried at how I'd managed to forget that A&E existed....

Last night I dreamt there was a very special revision lecture happening. I spent a long time trying to find out who was giving it, trying to track them down, and find out where the revision lecture was. This somehow related to a wall hanging. But I couldn't find the lecture, or who the lecturer might be (I was looking amongst friends and acquaintances, rather than anyone who actually is a lecturer), and I got very stressed about it.

If I carry on like this the nights for the next few weeks will be very interesting. And stressful. Why I didn't feel at all able to help the patient in the first dream I don't know, maybe it reflects my lack of confidence. And maybe the fact that I was so desparately searching for the revision lecture reflects my lack of sel-motivation and need to have people teach me rather than me learning anything for myself.


I hope I get some more sleep than this in the next few weeks though, I'm going to need it.






Dreams, by Fleetwood Mac. Who are wonderful (and were not in anyway murdered or destroyed by Glee - in fact that episode reminded me how amazing Fleetwood Mac's music is and made me dig out my old CDs)

There are no laurels to rest on

Nice as it was to learn that I'd passed all of my recent exams, that silver lining had a cloud. Yesterday I was given my exact marks for the exams, and discovered that my two recent practical exams were very, very narrow passes. By 4 or 5 marks, and since the overall exam has over a thousand marks, that is tiny. I scraped through both exams, and it was very very close. Too close, there's no margin for error.

The day of the big exam was a "good day". I'd done a load of confidence building and affirmations, put my positive mindset on, and got in the best frame of mind. Nothing at all went wrong, and I was the best I could be for almost all the exam (although towards the end of the three hours I did get pretty tired, everyone does). So if my absolute best is to scrape through with the tiniest margin of error, what happens if I'm not at my absolute best next time? I might have a streaming cold, a headache, too much nerves, a grumpy examiner - anything that could lose me those 4 or 5 marks.

This has at least put the frighteners on and given me a considerable kick up the rear to get me back into revising and not sitting around beinig complacent, but for a good 24 hours it pushed me too far. I think there's a scale of:
complacent, unmotivated, not working enough ----to---- motivated, hard-working, slightly scared but in a healthy way -----to---- panicked, totally terrified, unable to work, so convinced of failure what's the point in working
and I went from the left end to the right end, completely bypassing the healthy middle. An email from a friend, an email from a mentor, and some time with the other re-takers later, I'm feeling a bit less chicken-heady (I am no longer running around with my head chopped off, which I was mentally doing this morning). I'm towards the right of the middle and it would be good to get even further towards the middle.

It would be easier if I knew what I was actually doing wrong in the exams and had some idea of what to improve, but no, that would be too easy. Medical school is a cryptic crossword. It's very frustrating to have a station which I thought went amazingly (patient/actor clearly liked me, I asked all the questions for the diagnosis and all the others to rule out a differential diagnosis, I answered the viva questions brilliantly - I am not a show-off, but I thought it was my best station of the day), the examiner gave largely positive feedback comments, with the only negative that I was "a little slow to get through all the points" - this does at least suggest that I got through all the points, to fail the station getting a little over 50% of the marks. How does that work?!

So in the absence of really having an idea of what to improve, I just need to spend the next three weeks becoming the most incredible doctor all-round that there could possibly be. I will dazzle and amaze all the examiners. A tall order but who knows what could happen...

And I will not spend the next three weeks wondering whether these horrendous results suggest that actually I'm not really ready to be a doctor, and it would be much safer for me and the general public if I did re-take the year, learn how to be a good doctor, and make a better attempt next year when I actually know something. That is not productive thinking. But it is tempting.


The above is yet another reason why this blog is anonymous. My patients don't really want to know how much I've failed, or how close I came to failing. At least, they don't want to know that and then continue to be treated by me. And I will want them to continue to be treated by me - it would be embarassing for me and problematic for the hospital if not. Much as medicine is trying to break with the tradition of paternalistic "the patient doesn't want to know X [often that they had cancer]", I feel it's appropriate here if only for my own peace of mind. I want my patients to have confidence in me. If I pass, I've passed and I am good enough to be their doctor. If they knew the numbers this may be less obvious.

A passport to better service?

Conversation in the Boots pharmacy near the hospital:
me: Hello, one bottle of Movicol liquid* please
pharmacy man [patronisingly]: No, Movicol is a powder that comes in sachets. It's not a liquid.
me: Yes it is, it comes in bottles
pharmacy man: No, it doesn't
me: Yes....
pharmacy man: No, we don't have it.

He was patronising in the extreme, and seemingly isn't used to patients/customers who actually know what they're talking about. Or just assumes that patients/customers don't know what they're talking about.
I've been taking this medication for a while, I know exactly what it is, I don't talk rubbish. I resented the implication that I do.

I found myself regretting that my NHS hospital badge was in my bag and not visibly about my person, as it had been half an hour earlier. It may say medical student, and not 97% doctor, but I imagine it would make it clearer that I do know what I'm talking about. I am so intrigued as to how things might have gone differently if I had been wearing it - I think the conversation would have been very different.
Having said that, I hate the idea that a hospital badge could have been my passport to good service and pleasant treatment. No patient should be assumed to be stupid, and made to feel so, and have to argue to get their valid request across, whether they have a hospital badge or not.

I don't want to be treated better than other people by virtue of my education or profession, I'd rather everyone was treated better.

I really hope after I left he went away and looked up his formulary, so that next time someone asks, he knows that Movicol liquid does exist, and isn't rude. Though I just hope he isn't rude regardless.

*Movicol liquid is a bottle of mild laxative that is diluted and drunk. It's better than the sachets because from a big bottle the dosage can be altered on a daily basis as required, whereas sachets come in a set dosage size. The liquid hasn't been available for very long, and I found out about it from an advert in the BMJ - is that more proof that I know what I'm talking about?!
Direct-to-consumer advertising for prescription medications is not allowed in the UK, as far as I understand (although Movicol is available over the counter in pharmacies as well as on prescription), so the BMJ advert is aimed at prescribers. But that doesn't stop patients like me from seeing it!

Attempting to Access Adult Asperger Support Services Part 1

The Family Cracking-up-and-significant-breakdown Prevention Project (in family, I don't include my father - he's far too in his own head and own world to notice anything going on around him that could cause cracking up. That sounds like an insult; it's not, it's just how things are): so far, so good.

Whilst on an employability training scheme year, run by a special school, my sister spent a few nights at a residential independence skills training organisation, and that organisation will very happily take her again, on a regular basis. No prior assessments or referrals required. Hooray!

But this is only funded if she has a social worker. She last had a social worker under Children's Services. However, being a disabled and vulnerable child with a learning difficulty, requiring a social worker, seemingly does not mean one will become a disabled and vulnerable adult, with a learning difficulty, requiring a social worker. So she doesn't have one, and my next task is to get her one.

Once we've got her one, accessing this regular residential service should be easy, as the council's social services accept that independence training saves them a lot of money when the young person comes to move to a more independent place of living. A more independent person (as a result of independence training) requires less support, saving the council money.

So Part 2 will be obtaining a social work assessment. No idea how easy that will be or how long it will take.

Family wishes, difficulties and challenges

My mother has had an objectively more difficult life than anyone I've ever known. I wish she could accept that finding her difficult life difficult, or finding my very challenging sister* very challenging, does not make her a failure, and does not mean she has to tell the world she can't cope (she does cope, but sometimes she's pushed to the edge of coping-ability). I wish I had a way to make her know this.

This week I'm going to call up various agencies - I wish I could do more but even doing the small things is helpful, I hope. I'm calling because it's easier for me than for my mum to hear "No, we can't/won't help you / budget cuts / no space / we help people with learning disabilities, not "high-functioning" like Asperger's / we can't help people who are in employment"... those replies don't directly make my life more difficult, they're not as much a kick to the stomach when you're down as they could be for a primary cater facing challenging behaviour.

I so much hope I don't get those replies. Otherwise, well, it's convenient I'm living nearer family for my foundation programme years, because respite care (that I hope to help provide) is so essential. Especially when that care is mostly emotional.

*She has Asperger syndrome (an autistic spectrum disorder, at the high-funtioning end) amongst other diagnoses, so can have challenging behaviour.

Thank goodness for that

I passed my exams, I am deemed safe enough and competent enough to be an almost-doctor. But of course I am not yet a doctor, because I have the first-attempt re-take still to go in five weeks' time.

I've just passed four big exams, which should be a celebration, but all I can feel is relief: thank God for that, thank God that's over, thank God I don't have to do that again. Oh and hooray for me as well? Maybe. Not so sure about that bit.

The full extent of my celebrating has been having a cream tea yesterday, and a fancy readymeal from Waitrose. All of my friends who actually are now doctors (no re-takes for them) must have gone big on the celebrations yesterday, but they'll just have to join me in my celebrations come July. Or they won't because when I get my results, we'll all be on holiday.... but July can be my big party.

The only extra benefit of these results is that it gives more weight to the argument that my failure in January was the medical school's fault, not mine. Their "mishap" did throw me off, and now that I'm over that, nothing can throw me now.

There's very little to stop me now - four weeks of exam preparation, which is all re-learning things that I already know, and then time to ace the re-take, which I fully intend to. Medical school in its simplest form is five years, and when I started I was told it costs £250,000 to train a doctor (it's probably a fair bit more now). So after we passed each year, there were various claims of "I'm now two fifths a doctor!" or my favourite "I am now worth £100,000" (after passing two years).
So now that I've done 4 years and 34 weeks (out of 40) of a 5 year course (let's not include my extra years, for simplicity's sake - they weren't strictly medicine), that makes me 97% a doctor. And 97% of quarter of a million is £242,500 - that's what I'm worth! That's got to be something to celebrate... it's too much money for anyone to want to waste (though it wouldn't be the first time) so I am going to ace the June exam. With bells on.

Watch this space for the mega-big-time-party-celebration in July. In the meantime, thank goodness for that.

The biggest and finalest final

If it weren't for the pesky re-take I have to do in a few weeks, today could have been my last exam of medical school. It was the biggest, most comprehensive, and most terrifying exam of them all - the Medicine OSCE* (incorporating elderly care and mental health and anything at all that's not surgery, obstetrics, gynaecology and paediatrics). The one that if you fail, you can't work as a doctor for another year.

Today I wore the shirt that I wore to my interview to get into medical school 7 1/2 years ago, in 2004. It felt appropriately full circle. And if it was lucky then, it could be lucky now (though it was slightly on the tighter side now than then!). 

 

* OSCE = observed structured clinical examination. Big scary practical exam where you pretend to be a doctor, to prove you can. In a too short space of time, repeated many times over for half a day. The stuff of nightmares.

The loveliest statistician (i.e. geek)

The other day I had an exam in the morning, it was two hours long and a bit stressful. After joining the other half for lunch (amazing chilli nachos), I spent the afternoon with a good friend. We spent about four hours working on her medical dissertation project, which needed some statistics. I have the statistics programme, SPSS, went to lots of statistics courses last year (which I STILL have yet to be reimbursed for) and my dissertation last year was basically all statistics, which I had to teach myself and do myself, so I can sort of hold my own when it comes to medical statistics.

Although it took a fair bit of brain-effort to recall everything I’d forgotten over the past year, this came in very useful for my friend. Her project has gone from having some percentages that look quite nice, to having Chi-squared for trend with a p value less than 0.001 – to anyone who knows research, that’s gone from “somebody found that the intervention probably changed things a bit” to “they found that changes resulting from the intervention were highly significant, with a less than one in 1000 possibility that they were just caused by chance, therefore these interventions are good and everyone should adopt them”. We also added in some nice standard deviations because ranges should be left behind at Maths GCSE.

Surprisingly successful for a post-exam afternoon, where the temptation to just slump is strong. Instead we spent hours fiddling with SPSS, transferring her data from Excel to SPSS, making new data files, fiddling until we found some results that meant something, were the right type of statistics, and were reproducible for the rest of her data. But the worst of it is: I really enjoyed it. I feel I shouldn’t admit to this. This is statistics after all – possibly the most boring thing I’ve ever had to learn about throughout both my medical and genetics degrees. It is the realm of geeks of the dullest kind. I’m not going to deny my geekness, I did do a genetics degree after all, but statistics geekery is a few steps too far; I am not that boring! Learning about stats is mindnumbing, but actually implementing it, playing with SPSS sot that you get something shiny and publishable – I’ll be honest, that is fun. It’s experimentation, with useful results.

I feel I should embrace my inner stats-geek, and have a potential idea: I’ll become a FREElance statistician, as a junior doctor. Here’s the deal – you (consultant, researcher, clinician, nurse specialist, whoever) have a research project that you hope will show something exciting, and you’ll want to tell the world about it. I am an academic junior doctor, and I will do your boring statistics for you. Give me your data, and I’ll give you the shiny publishable results. If you ask nicely, I’ll even write your results up for you (I like a nicely displayed table). I will not write anything else – your introduction and discussion and all the wordy bits are yours alone (I hate writing). I’ll write the paragraph on how I analysed the results, I’d have to really. And the best bit: I’ll do all this for free. All I require is that you put my name on your publication or conference abstract, after all, I will have contributed to it.

And if you’re really organised, I can discuss your data collection methods with you before you start, to ensure you’re collecting the best data to get the best results.

Do we have a deal? What’s not to like?! I would love to know if this would actually work in reality. If you (non-existent readers) know anyone who needs some medical stats… Trying To Be A Medical Student is here to help – you know where to find me.

Win-win situation: the researchers who don’t have time or understanding or patience or SPSS get their statistics done for them, I get more research experience, and I get published, which can only help my academic career. And will add something non-gynaecology-related to my CV, and since that’s not an area I plan to go into (never going to be a surgeon), that would be useful.

Here’s to embracing the inner geek. And to helping friends out.

Saving the world, one starfish at a time (or not)

Before I start, I am under no illusions - I am not saving the world!

This morning, as I went out early, I found a starfish on the pavement, just by the doorstep. A real starfish - the photo is at the bottom. It looked wet and it seemed reasonable to think it might still be alive. I was amazed and wondered if the storm or rain last night had really been bad enough to pick up a starfish and carry it the 500m+ it would need to travel.... and rushed off to my appointment.
When I got back half an hour later, it was still there, so I took photos, and went to tell other half about it. He very sensibly pointed out that it was probably dropped there by a seagull (not as exciting as the idea of wether-induced flying starfish, but far more plausible). I dragged him out of bed and we hatched a plan to take it back to its home and put it in the sea.

I'll explain here that there is a sort of parable by which I'd like to live my life, commonly known as "the starfish story" or The Star Thrower, written by Loren Eiseley in 1969. It's been re-told many times in different ways, and I heard about it from my utterly uninspiring headteacher, who managed to inspire me with this - I can't remember anything else remotely inspirational or even interesting that he ever said.
The version I remember I think of as having a small boy as the thrower, others have an old man or a girl. The beach is covered in starfish which have been washed up after a storm. Someone, let's say a small boy, is walking along the beach, throwing starfish back into the sea, one by one. Someone else, I think an old man, walks up to him and says "why are you doing this? there are thousands of starfish here, you can't possibly make a difference". The boy picks up another starfish and throws it, saying "I made a difference to that one".

It's such a simple, beautiful story, and although I don't think of it often, it's stayed with me over the years. I understood the message to be: you don't have to change the whole world, but you can make a difference to someone, or even a few people. Even if you make a difference only to a few, you have still made a difference, you can still change lives.

Others perceive it as meaning you should do what you believe in no matter the criticism. On looking it up just now, some versions have the old man deciding to join the boy in throwing the starfish, and more and more people join in, ending with the rather twee "all the starfish were saved" (personally I don't think saving all the starfish is the point, I think the point is that it is always worth making a difference, even if you can't make a difference for everyone; you can't save the world - saving all the starfish kind of is saving the world, and feels unrealistic). In that version, the message can be that you achieve something if you all work together, or if you can persuade everyone that it is worth making a difference.

I think this story is one of the things that spurs me on to do what I do, or what I'm going to do, be it medicine, volunteering with seriously ill children (more on that another time), campaigning, volunteering in schools... Each patient in my medical career could be a potential starfish. Not that they've all come to me to be saved, but that even if I can't do everything, I can still make a difference. To remind me of this, I have two beautiful pictures of starfish - one a birthday card from the other half some years ago, and one a sparkly postcard I bought last year while presenting my work at a conference abroad. I want to frame them both.

Back to this morning: given that this story really means something to me, I thought it would be a great idea to live in out (on a minute scale) myself, and take our doorstep starfish back to the sea. I didn't want to do it on my own - I thought I might need help (my intention was to carry it on a baking tray, I thought that way it might not dry out too much), I wanted it to document the starfish saving adventure photographically, and also I thought I would feel less silly and look less nuts if there were two of us poking and picking up a starfish and carrying it along. So I woke up the other half, got back in bed for a bit, waited for him to properly wake up and get dressed and got some plastic bags and an oven tray together, took other half outside with me.... only to find the starfish had gone. I don't know what happened. Maybe another seagull came along and thought it looked tasty. Maybe the first seagull wanted another go. Maybe some other people had the same idea and got there first, and the starfish is now happily floating away.... I'll never know. But I'm kind of kicking myself for not getting straight back outside and doing it myself. Specially if the seagulls got it.

I don't even know if it was still alive in the first place. But I'm still a bit sad about it - next time I'll seize the opportunity to throw a starfish when I see it, not half an hour later.

However, the positives: I saw a starfish! I never even knew they lived in this country.
In this time of considerable stress about exams, whether I'm good enough to pass, whether I'm good enough to be a doctor, whether I even really want to be a junior doctor with the stress and responsibility and total lack of confidence in my non-existent abilities that that involves, it was nice to be reminded of a reason why I came here in the first place - to make a difference, even if only to a few starfish out of thousands. That I can be that difference, and that it's worth it even if you can't save the world.

To have a real starfish to remind my of all this, to make me keep going - maybe that starfish was on my doorstep for a reason. I don't believe in fate - that would have been a nice explanation. But sometimes things happen for a reason, and today's starfish could have been there to rejuvenate and encourage me, to remind me to keep going. So I will.

[I realise this post could give away where I am, and therefore which medical school I'm at. And this is supposedly an anonymous blog. Please note I am not necessarily at home, or not necessarily at the place where I study - I might have gone away somewhere. Or be staying with family. You never know - make no assumptions.]

Dignity

Today I was writing notes on practical procedures, for practical exam revision. Specifically, I was writing about male catheterisation, which is a complicated process, so I made a nice step-by-step flow-chart.

One of my flow-chart boxes said simply "expose patient, maintain dignity". That's all it needed to say for th purposes of my notes, but it struck me how unrealistic that is; if it were as easy as just writing it in a flow-chart box and it were magically done, all hospital patients would be wonderfully dignified. Even whilst being catheterised (I've been catheterised; it is an unpleasant and rather undignified procedure, and I know that even without full recollection if it - I was still woozy from the general anaesthetic).

I love the idea that one could just mentally note "maintain dignity" and that would be all it took. It's so far from the truth. In all honesty, I don't even know how to maintain someone's dignity, particularly when they're being catheterised. I find it especially difficult with old people, more so when dementia is a feature (that's another post for another time). Being professional I'm sure helps, but there's more to it than that.

And I certainly don't know how to maintain it since when going over my notes I discovered I had forgotten that vital step "cover patient with sterile drape" - sheet with small hole for penis to protrude onto sterile field is going to provide somewhat more dignity than general genital exposure. Woops. The sheet is in the catheter pack, so it's unlikely I'd forget when I'm actually trying to do it.

I also forgot to mention the essential step of "reposition foreskin" - if the foreskin is retracted for a long period of time, scarring and serious damage can result. I should be able to do this in practice; the first time I observed a male catheterisation, the doctor had forgotten to do this and I reminded them, so I should be ok (as should the patient's penis).

For now, all my brief notes can really include is the simple "maintain dignity", but at least it will serve as a reminder that in practice, this is always something to consider. It will remind me to think about the patient's dignity, even if achieving it is a task that seems mysterious, difficult, and at times, impossible.

Medicine is funny, bodies are strange.... aka I know nothing

I took myself to the doctor today, had been putting it off for a while, but now I had a weird mouth pain. It had been there a few days, under my tongue, on one side. I'd decided it had something to do with a salivary gland (there's not really anything else under the tongue that's likely to cause pain, I thought), either a stone, or it had got infected.

I hadn’t found anything under my tongue, and neither could the doctor. He proded my neck a bit, which was surprisingly painful, and concluded I had a swollen lymph node, which could be causing the under-tongue pain. I hadn't noticed it, and still can't really feel it now if I palpate my neck - don't come to me with your swollen lymph nodes, people. I may not notice them.

Just as he was about to move on from the mouth/tongue/neck, he had a quick glance at my throat, just to check. "Aha! That's what it is!" he proclaimed - he might as well have shouted "BINGO!" He had found an aphthous ulcer (a common mouth ulcer) on the corner-roof of my mouth. He seemed very impressed at how big it was, and told me to go and have a look in the mirror when I got home. I duly obeyed, and he was right - it's big, white, and very obvious. It looks like something out of a medical textbook, near the uvula (dangly bit in the middle) and very obvious.

But here's the bit I find weird: it doesn't feel anything like a mouth ulcer. I've had plenty in my time. And they've all been really, really sore and very easy to locate; the pain lets you know precisely where they are. I'm given to understand that that's what mouth ulcers feel like for everyone, no?

Not this one. It's not really sore at all, not in the way that I could point a finger at it, rather that I can only wave a hand around the left part of my face and neck and say "it hurts in this general direction", yet clearly it's the same disease process and tissue breakdown. This isn't to say it's not painful, it's just differently painful. Though it got more painful after I'd seen it and knew what it was, silly brain!

So I'm really intrigued as to why the difference, and wonder whether the back of the mouth has some kind of different nerve innervation. I wish I knew more than that.

But at least I've learnt: don't make assumptions about one's own health problems, don't jump to conclusions, and aphthous ulcers do not always present with a typical history. For medics out there - if you have a patient presenting with a vague neck or mouth pain, check the back of their mouth and their throat. Even if the pain doesn't sound like it's coming from there.

Learning point - I need to improve my neck palpation and ability to detect swollen lymph nodes.

Overall, a productive learning experience!