Comics in medicine

I went to a really interesting talk on comics in medicine, and since it was fascinating I might as well write about it.

There were three speakers, one a doctor who writes comics about her experiences in medicine, one who wrote a graphic novel about the death of her two year old son, and people's reactions to this, and one who wrote a graphic novel about caring for his dying father. I haven't read the novels, though bought them today for post-exam enjoyment. I've never read a graphic novel at all, actually, but have been introduced to the idea of comics being useful for talking about and learning about health and medicine and particularly mental health from I do not have an eating disorder, from which I have learnt so much.

The talks were fascinating, though more academic than I expected - there were discussions on reflection, ethics, narratives and other complex concepts; for some of it I had to stretch my brain cells a bit remembering back to what I learnt about ethics in theology/religious studies A Level! Not what I'd been expecting from a talk about comics, but really interesting. Especially how comics are in the middle of some Venn diagrams, such as  medicine, ethics and art, and also medicine, humour/humanity, and I can't quite remember the third part, it might have been ethics again.

Some points that particularly struck me - a discussion of the expertise of lived experience versus learned expertise. That's one to think about. I think a lot of medical students and junior doctors are probably lacking in the lived experience, but still feel like, or are made to feel like, experts.

Another point was that these comics and graphic novels were not written for catharsis, not to make the author feel better, but more to develop a narrative, "writing to work out what you're writing about" but with drawing as well as writing. One speaker said that catharsis dries up after 10 pages. That struck me since I said the other day that blogging could be cathartic... but I don't want it to be just cathartic, I want it to develop some ideas (I have many) and raise issues and share thinking and not just be a way for me to feel better. So that's my plan.

I also got a super-cool person cartoon-comicbook-character drawn specially for me inside one of the books I bought. It's wishing me luck for my exams.

And I've got recommendations of other things I should read when exams are over. I also read something that reminded me of my intention to read Armistead Maupin when exams are over, must remember that.

So overall, an event worth attending, really made me think, and wonderful to get away from textbooks and learn about amazing books for a bit instead.


Made me kind of wish I could draw comics, and I'd thought that my total lack of artistic skills would make that impossible, but I learnt that comics don't have to be artistically skilled... but I think I have too many words to fit into comic format. And I don't have the kind of imagination for it. Maybe I'll give it a go one day.

Mnemonics for pharmacology and therapeutics

There's been much discussion of mnemonics for drugs, and just in case other medical students ever come across this blog, I thought I'd post them here (you never know, it might increase traffic to the site). I can't claim authorship of any of these, I got them all from friends - some may have come directly from, or been modified from books.

Enzyme Inhibitors - SickFaces.com
Sodium Valproate (anti-epileptic, also used for bipolar disorder)
Isoniazid (used for TB)
Cimetidine (an H2 receptor blocker)
Ketoconazole & fluconazole (anti-fungals)

Fluoxetine (a selective serotonin reuptake inhibitor)
Alcohol - acute consumption & cigarettes
Cardiac failure and liver failure
Erythromycin & clarithromycin (macrolide antibiotics)
Sulphonamides (antibiotics)
.
Ciprofloxacin (a quinolone antibiotic, which can cause tendonitis and tendon rupture)
Omeprazole (a proton-pump inhibitor)
Metronidazole (antibiotic effective against anaerobes)

These all inhibit enzymes and therefore can increase the amount of a drug that is metabolised by the enzymes that are inhibited, as less of the drug is being metabolised. Therefore, these drugs will increase INR as they inhibit warfarin metabolism.

Apparently amiodarone and grapefruit can also go in this group (which is why patients on some medications are advised not to drink grapefruit juice), and also ritonavir, a protease inhibitor used for HIV. However ritonavir's enzyme inhibition is useful as it increases the amount of other HIV drugs, so is always given in combination with another HIV drug to "boost" it. 


Enzyme Inducers - Crap GPs (not very respectful to GPs I know, but they can't all be good, there must be some crap ones)
Carbamazepine (anti-epileptic)
Rifampicin (antibiotic, particuarly used for TB)
Alcohol - chronic consumption
Phenytoin (anti-epileptic)

Griseolfin (anti-fungal - I've never heard of it, apparently been largely replaced by terbinafine)
Phenobarbitone (old-style anti-epileptic, not commonly used, not first-line)
Sulphonylureas (anti-diabetic drugs, e.g. gliclazide) & St John's Wort (herbal remedy used for depression - available off the shelf in Boots even though it could dangerously interfere with lots of drugs... but I guess so can alcohol)

These all induce enzymes, so will decrease the amount of a drug, as the induced enzymes metabolise more of the drug. They will decrease the INR, possibly below the therapeutic level, as more warfarin is being metabolised.
Worth noting that carbamazepine and phenytoin induce the enzymes that they themselves are metabolised by, so they induce their own metabolism. I think this is why you have to gradually increase the dose of them, as the more they induce the enzymes, the less of the drug you have, so you have to increase the dose. But only up to a point - not sure why that is. Maybe there is a maximum amount that the enzymes can be induced, I don't know.


Drugs metabolised by cytochrome P450 - Cow Pats
Ciclosporin (affects the immune system, used post-transplant and for psoriasis), carbamazepine (anti-epileptic), citalopram (selective serotonin reuptake inhibitor, first-line treatment for depression)
Oral contraceptive pill (contraceptive - very important!)
Warfarin (anti-coagulant)

Phenytoin (anti-epileptic) and protease inhibitors (a type of HIV drug)
Acetylcholinesterase inhibitors (eg Donepezil, used for Alzheimer's disease)
Theophylline (used for severe asthma) and tacrolimus (immune modulator, used for eczema and psoriasis, I think)
Statins (used to decrease cholesterol, particularly LDL) and steroids (used for loads of things! Auto-immune and rheumatological conditions, for example)

The only problem with this one is that you have to remember there are three Cs, two Ps, two Ts, and two Ss, which isn't reflected in the Cow Pats mnemonic.
The inclusion of warfarin in this list reflects what I said above about other drugs affecting INR. Thyroxine also affects warfarin, but maybe not through enzymes and that's why it's not on these lists.
Phenytoin and carbamazepine here, reflect what I said about enzyme induction.
Protease inhibitors here, that's why their metabolism is inhibited by ritonavir, as above.

That's all the therapeutics mnemonics I have for now! Maybe I'll have more mnemonics for something another day. Note mNEmonic, not pneumonic as Podmedics and loads of others pronounce it - these memory aids have nothing to do with air or lungs!

Apologies to the non-medics for the boring nature of this post. Normal waffley service will resume soon. Though I do like the opportunity to write a blog that contributes to the amount of work I've done today!

Ouch... and breathe.

Wow, you could even smell the despair in that last post on Sunday, couldn't you? Apologies for that. I have picked myself up a bit since then.

I've been doing considerably better mentally, partly from attending revision lectures in which I actually understood what was going on (very reassuring) and even did ok in the questions they asked in the lectures, so all cannot be lost. I think the biggest difference by far was made by hearing how lots of other students are feeling as horrendous as I was. I'm not in this alone - that makes everything a lot better.
And if we are all filled with dread and terror and fear, that must be ok because we can't all fail, right? At least, none of my friends failed in January and they seemed about as nervous then as I was.
I've also done some bits of practising skills, and although I'm fully aware I need to be working on confidence, it's good to feel like I'm making a start at getting there. I just hope others are as intent on group practising as I am, I think that's the key.

Also spending time with other people helps, I think it leaves me alone with my thoughts less, which means less despair. Much of this week I've been hanging around with friends between lectures, and half of that has been spent working or practising or discussing revision but that's ok, because it's still with other people who have the same problems I do. Maybe not quite the same extent of procrastination, but definitely some.

Another helpful thing was making a tally chart spreadsheet thingy on Excel to mark of what work I've done, how I've done it (podcasts, books, questions etc), what areas I've worked on, which has the two benefits of being able to see how much I've done and feel good about it, and also to see which areas I need to do more work on. So today I have mostly focused on Infectious Diseases and that row in the chart will soon become nice and colourful. As will my infection knowledge, hopefully.

I decided on Monday that I needed to make an effort to do things to preserve sanity - exams and exam thoughts cannot take up all my brain time. So Monday I went for a bit of a run on the way to and from the supermarket, which felt really good (very much a bit of a run, not a proper run - I'm using the first week of CouchTo5K to help, but I only do it occasionally so haven't got past the first week!), watched an episode of Glee which is awesome. Yesterday I realised late that I hadn't done anything to maintain sanity, so we listened to the News Quiz in bed - I am a massive Radio 4 comedy fan. And today a friend came round which was really lovely; we ate together, and I worked while she and other half watched a film, then we all had ice cream, and we watched some exam revision videos together (she's a medic in the year below, so it;s useful for her too) so it was sociable and work at the same time. It gives me more incentive to get the work done if there's fun stuff to do and people to chat to one I've done it :)
 So I'm planning to do something vaguely sanity-maintaining each day. I hope that will prevent me going as up the wall with despair as I did on Sunday.

I should note, just because I'm doing better in myself, doesn't necessarily mean I'm doing more work. It doesn't seem to be that simple, unfortunately. Today has been pretty good though.

I want to fail

Before I go much further, I should update this, that I failed one of the final exams this year. Taking the title of this blog literally – trying, but not succeeding, to be a medical student…

It was a big deal at the time (I wrote a blogpost about it in my head, entitled [insert list of expletives here] because that was how it felt) and a big stress involving an appeals process relating to a “procedural error” during the exam, which was not in any way caused by me but impacted considerably on me (and only me). The appeal took two months, but was eventually as successful as it was ever going to be (not necessarily as successful as I’d have liked) and I’m allowed to take the re-take as though it’s my first attempt. This has no effect on the actual resit itself, but means that if I fail it, the medical school won’t be able to kick me out as they otherwise might have been able to. It guarantees me a third go, were I to need one. Let’s hope it doesn’t get to that, it’s already dragged on long enough.

So the advantage of this appeal result for now is simply in stress management – I should be less stressed going into it knowing that it’s not my last attempt, not a sudden death situation. And should therefore be more likely to do ok, at least that’s the theory.
(The other advantage is that it could, just possibly, be perceived as the medical school admitting responsibility for the “error” – which has not happened so far, and has not explicitly been said (quite the opposite, I was told it was one examiner’s fault and therefore not the medical school’s responsibility) but perhaps this appeal indicates that it was their responsibility. An apology would have been nice too, but I won’t ask for miracles.)

The re-take will be a three and a half hour long practical exam (as was the first one) at some point in June; I don’t anticipate finding out when any time soon – that would be far too useful.

So I have four final exams in the next four weeks, culminating in the massive scary practical one that expects me to know everything and prove I’m good enough to be a doctor. Which I’m not (obviously). Not yet anyway.
And then around four to six weeks after that, I’ve got the re-take of the one I’ve failed. Which is equally as big, but probably requires a bit less knowledge, and is re-learning what I learnt last time, rather than just learning, which is what I’m currently doing. And since I failed it by 3% last time, my chances can’t be too bad. And then about three weeks after the last exam (or medical placement or other medical school commitment, whichever comes later) I start work. I do six days of shadowing the junior doctor I’m going to take over from, and then on the 1st of August, same day as all the other junior doctors in the country, I start working properly.


Back to now: I very much wanted to pass all the exams in January. But this time around, I’m not sure if I care. Or even, I can see the benefits of not passing.
It would at least mean I get a break. If I fail something in May, if it’s a minor thing I might be able to re-take it in June with the other one. If it’s the major one I have to re-take in November, or re-take the year. If I fail more than one, I definitely re-take the year. Re-taking the year would not be fun – I haven’t particularly enjoyed it first time around, but I do have some friends in the year below (including a very good friend who is lovely), and I’d get through it, and maybe it would be good to understand what I’m seeing in practice, rather the see it and then understand later when it comes to revision/learning. Though that didn't apply to everything.

But the most important bit: if I failed in May and had to re-take the year, I would have no commitments between May and re-starting the year at the end of August. Three months with nothing. No commitments, nothing, just time to re-learn how to be a human being rather than a vile, miserable stressbag that is set to implode at any second. I like the idea of being a human being.

I know I said that I get three weeks off between end of exams and commitments, and starting work. Plenty of people could say that I’m lucky to get three weeks, that’s as much holiday as they get all year (and it’s not the only holiday I’ll get – I imagine I’ll have at least two weeks holiday from the job before the end of this calendar year). But those three weeks won’t fully be holiday. I’ll still be stressed for at least one week of it, or however long it takes for the medical school to give me my results. And I’ll be moving house, moving cities and finding somewhere to move to if I haven’t already found it by then. I’ll be moving away from the other half, which will be sad as it’s been quite nice living together again these last 6 months. Nice for me, not for him – I wouldn’t want to live with me at the moment.

So let’s say I get two weeks between getting my results saying I’ve passed and am allowed to be a proper doctor, and starting work. And though I intend to holiday then, though not quite sure of the details since other half’s job does not allow holiday in July or August (bit of a bummer when the only time properly off I’ve had this year has been one week in January and the three weeks in July. But a job is a job, so cannot complain), those two weeks will have some elements of stress to them.

For those that think that students doss around and being a student is a perpetual holiday, 2012 has mapped out thus: January – massive revision, final exams, one week off. February and March – full-time placements (full-time being around 8.30 til anytime between 3 and 8, minimum 4.5 days a week), three pieces of horrible written coursework case reports, compiling the horrendous and enormous student formulary, which is just a giant list of 180 drugs and everything you might want to know about them, and completing all the clinical skills for the year. Which I made difficult for myself by losing my skills book in December, and having to start all over again in February. April – one week of placement, one week full-time revision (“vacation” is a lie), two weeks organised revision with lectures etc, then final exams. May – final exams, one week off, which isn’t really when you have a re-take in June looming, then placements and/or intensive revision for the re-take. June – more intensive revision, re-take final exam, then more placements as required. I hope that makes clear that my requirement for some actual time off is not me being pathetic. The only time off I’ll have had all year, the only time off since August last year, was one week in January. Not enough to maintain sanity.

Anyway, my main point is that two weeks is unlikely to be enough to re-learn how to be a human being. Or to fully catch up on sleep and learn how to sleep properly again (I can't remember when I last had a good night's sleep). Especially not two weeks involving moving house and beginning to become slightly petrified about actually having people’s lives as my responsibility.

So failing and having three months off becomes more and more appealing. Which might explain my total and complete lack of motivation for revision and working and any kind of real exam preparation.

The other possibility is failing the big one and re-taking it in November, which would give me five months between the last June exam and the re-take in November, a little time to re-gain my sense of human. And the best bit – no commitments between November and the following July. Seven+ months in which to go nuts and have a great time, go travelling, well and truly re-learn how to be a human being and maybe even how to be a good one. Put it into practice.

The only reason not to go ahead with this genius plan is that I’d lose my academic foundation programme. Which is potentially my passport to whatever post-graduate training I want, and an overall good career. Seems a shame to forgo that. There’s also the issue that I’d have to do all of the exams all over again, but I think doing them a year later (or even five months later with the November option) and with some pre-existing knowledge, I’d stand a much better chance.

Maybe the academic place is a good thing, as it’s the only thing really keeping me going. Though it’s not doing a very good job of that at all, since I’ve been averaging less than two hours work a day this week. Admittedly there have been some revision lectures, and I spent yesterday at a revision course (watch this space for a review) but even so, an hour or two a day is pathetic. And nowhere near enough to pass the big ones.

But despite the incentive of the academic place, I can’t really bring myself to care. I imagine if I do fail, I’ll look back at this post with great regret and think about what an idiot I was. Whilst enjoying my three month long holiday, becoming a better person, and having a great time…

Maybe this is all just because I can’t in any way envisage myself passing (the last time I passed all my exams including practical ones was four years ago, and I’ve got a lot less good since then), so rather than dwelling on that negative, I’m looking for the silver linings in the, what currently feels inevitable, failure. It’s a shame the silver linings seem so tempting.
And that the academic programme isn’t as much of a carrot as I had hoped. Anyone have any tips on where to find motivation when all you need is some time off? I’ve already tried down the back of the sofa, and it wasn’t there.

(Feels a bit silly asking for tips, when no one's ever commented on anything in the year and a half history of this blog... maybe I need to find some readers, an audience. If you've read this, share it?)

Procrastination is killing my blog

Not because I procrastinate about writing blogposts, it's more a matter of finding time. But I have a massive amount of work to do - have had since end of Feb, will have til end of June. And although I've finally handed everything in and all that remains is finals, I am very bad at getting work done. So I've blocked the entire internet for the daytimes, and blocked Facebook and blog sites into the evening - including my own blog. Also blocked everything overnight to minimise the preventions to a normal sleep pattern. Leechblock is wonderful when you have no willpower (and when it works and FireFox works - mostly).
Yes I could write in Word and just post online in my permitted two minutes (in every two hours) but given the current situation of my lack of revision, would be very risky.

I still write blogs in my head on a regular basis. Not that there's much point - that's just an internal monologue.

But right now I'm on a train, on my phone - which will prevent excessive waffling since typing on this is slow and frustrating.

I probably should try to blog more often, it might be a bit cathartic and help reduce stress levels, which, pre-finals, are definitely on the way up.
I have lots of planned blogs. Making time for them to materialise would require lots of organisation... you never know.