The SJT

Hi,


Despite my new start on an obstetrics and gynaecology rotation this week, the most 'important' thing that happened was sitting the 'Situational Judgement Test' (SJT) - if you want to have a bash at it yourself click here for the official practice site. The SJT is a test which gives you multiple choice options for 'situations' you may find yourself in as a foundation doctor, meaning it is not really knowledge based. This is the first year it has been used properly, so we will see what happens, and it is a test that every final year medical student in the UK now has to sit. It is important, as the results are used to allocate where you work on graduating, and which jobs you get. Do well and you could be doing paediatric surgery in GOSH (if you want...), do badly and you could end up in the Shetney Islands working with incontinent sheep... Well, perhaps not, but you get the idea.

The main problem with this test is that, amongst my year at least, it is perceived as much more of a luck-based-exercise rather than something that requires any skill. One of my friends was telling me that during the pilot phase, two groups were set the SJT, one who had been coached to do well, and the other one hadn't. No difference was seen between the two groups, suggesting that you couldn't practice for it. I don't really like this, as surely you should be able to practice for pretty much anything, from hard maths to soft 'communication skills' - they should all be something that you can practice and get better at. If practising the SJT questions doesn't make any statistical difference, then to me this suggests that the test is far more luck based than anything. After all, you could coach me for a year, but I wouldn't be able to get a (fair) dice to roll any more sixes than you could... 

As you can imagine, the feeling that where we will have to work in future, and the jobs that we can get is being decided by fortune has lead to plenty of outraged Facebook statuses and the like, but sadly there is little that can be done. Despite this feeling that it was luck-based, everyone (myself included) practiced as much as possible for it in the hope to get better scores. It would be stupid not to. I got a couple of books out of the library and have signed up to Pastest for exam revision (generally seen to be one of the better online question banks) as they also have SJT practice questions available.

The problem was, the books all contradicted each other. I looked at three in the end, 250 SJTs, the Oxford Assess one and a Third one. Of the three, I preferred the Oxford Assess one, though in some way or other they all contradicted one another at certain points. If they cannot agree on answers to questions, then how are we meant to be able to guess ourselves! Often picking the best one or two answers is pretty easy, but it is when ranking the 'inappropriate' ones that things get difficult. If the answers are all wrong, it is hard to decide which are more and less wrong. For example, in Pastest, there is a question about walking in on your registrar watching pornography in the mess, and you have to chose what to do about it. Pastest have decided that calling the police 'ranks higher' than doing nothing at all. I disagreed with this, as what interest would the police have in something which is not a criminal matter? Sure, it is very unprofessional, but I don't think the police would come and perform an arrest (though if it involved children I am sure it would be a very different story). I filled in a box at the bottom of the pastest page, saying I disagreed, and I got a very snotty email back from them telling me I was being foolish, and linking me to this article (which tells us the police did not bring charges anyway). I was impressed that they replied, and backed up their argument with a newspaper story, though. Despite this, the next day I was doing questions from the 250 SJTs book, and the exact same question came up, very almost word for word. the 250 SJT book had different answers, and told me that the police definitely wouldn't be called, as they were not breaking the law, and the police wouldn't be able to do anything. Crazy.

Anyway, the test went OK, though it is very hard to tell how well something that seems to have very little basis on fact went. I am not sure if the practice I did before helped, but at least if I do poorly and do end up working somewhere I don't want, I will not feel that it is through lack of trying. This whole section has turned into a bit of a rant about this test, so I am sorry about that!

In other news, this week I also spent time in gynaecology clinics, antenatal clinics and practising suturing with a very friendly consultant who will hopefully let me practice on real patients next week. The gynaecology team is lovely and very inclusive, so hopefully I will have a lot more to talk about next week when I am not raging about this test...

I will keep you updated on how my application goes, though I will not find out until February. 

Illness

Hi,


A late post, yet again, but I have been ill so perhaps that goes some way towards an excuse... This was my second (and last) week of paediatrics, so I spent time on the wards and ended up catching an infection from one of the ill little kids... The main thing of interest that happened this week (apart from the really important medical student getting ill) was a fantastic piece of clinical detective work which came from one of the doctors on the ward; something House MD would have been proud of.

Me being ill isn't really blog-worthy, so I will brush over it. There are a lot of sick children in paediatrics, especially babies with bronchiolitis around this time of year. I think one infected me with a virus (perhaps RSV, who knows) and I had to take the last day and half off last week with general coryzal symptoms, generalised myalgia and headache... Or man-flu... whichever you think fits best. I am feeling a lot better now, though.

It is a terrible disease... Honest...

Back on track, I spent most of the week when I was in hospital in a variety of different ward rounds and clinics with the nasty children which then went to make me ill. The best part was during a handover, when all of the patients are discussed between the day and night team, to make sure everyone knows what is happening with each patient at that moment in time. One of the patients, lets call him Billy, had been in the ward for the last few weeks, and was receiving chemotherapy for a rare type of cancer that had started in his tummy, but spread out across his body. The subsequent scans had suggested that this treatment was being very effective in controlling the cancer, and it was all shrinking, but overnight the night team had noticed that one of his pupils had become fixed and dilated (a blown pupil).

Blown pupil seen here in the patient's left eye

This raised a lot of worries, most importantly the worry that the cancer had spread to the brain, and was growing there, affecting the nerves coming out of the brain by pressing on them and creating this symptom. The night team had arranged a whole host of brain scans and investigations to be carried out this day to find out what was happening. One of the paediatric consultants, who always dresses pretty shambolically and behaves a little like a crazed professor started asking the night team questions

"Is the patient on hyoscine for the chemotherapy?"

Yes he is, they answered, he has a patch on at the moment

"Where is this patch, is it on his neck perchance?"

Why yes, its on the left of his neck, a bit above the clavicle"

"Well that is the answer, then. Hyoscine is an antimuscarinic, and the drug is passing through the skin into the blood vessels which then feed into the eye, dilating the pupil. Change the position of the patch."

And hey-presto, the patch position was changed to the other side of the neck, and the eye slowly went back to normal. A lot of stress for Billy and his parents avoided, and a lot of expensive (and radiation-filled) scans avoided. A simple diagnosis made without any fancy hospital tests, just a brain. That is the way medicine should be done!

To wrap up, the boy who was hallucinating snakes was discharged this week, with no medical cause found for these sightings. This is good, as it means he hadn't accidentally eaten some illegal/legal drugs, and he didn't have a brain tumour, but it did leave a question mark over the diagnosis. The children's psychiatric team were involved, who decided he seemed he may be slightly on the autistic spectrum (and wanted to follow him up), but they were not sure where these hallucinations came from either. The final decision was it must have been a nightmare which had started this off, and the psychological trauma which this nightmare (i suppose about snakes) had caused had lead to these hallucinations. This has been documented before. Not a perfect answer like I was hoping for, but it is the best we could get... A little like the finale of lost.

Hallucinating snakes

Hi,


A change of rotation again today, and onto paediatrics. The best part of this is the fact that I only need to be in at 9AM every day, meaning I get at least an hour of lie in extra compared to the last four months. Obviously this is not the only positive part of the change, and there are a lot of other lovely things around this change. Changing team is a shame, as the F1 I was with was lovely, though this hospital's paediatricians are also very nice. There are no F1s (first year junior doctors) on this hospital's paediatric wards, so this week I spend all of my time spread between a couple of different consultants and the doctors on their teams. Following consultants around is a little different to what I have been doing before, where I have been following around the most junior members of the medical team. This means I get less hands-on experience of what to do next year, but it does lead to a lot more teaching opportunities! 

The team I am with for the next two weeks (yes, that is all my rotation is, a measly two weeks) is really lovely, and I quickly felt settled in and at home. I suppose you would expect paediatricians to be caring, lovely people, if they wanted to look after children, but by the same logic you would hope that all doctors would be very helpful, as they have all chosen a caring profession! The consultants seem very keen on teaching, and the more junior members (who are all still a good few years post-graduation) are very happy to let us get involved, clerking children in when they are admitted to the hospital and doing as much as possible on the ward.

Each day starts with a morning meeting, which is why it cannot start earlier than 9. All of the patients who are in the hospital are discussed between the doctors, and treatment plans decided for each one. There are two main sections to the paediatric work, one dealing with the babies, I.e. those who have just been born or those who were born pre-term, and the other dealing with babies, children and adolescents with any problems that come after birth.

I split my time between the two sections this week, spending some time with the newborn babies doing baby checks. A great chance for me to practice this, which would make a good examination come finals, though it does open you up to be showered in wee by little baby boys... Less said about that the better. 

The other section involves ward rounds, diagnosis and treatment, much like any other medical ward, but in children. There is a large range of patients in the ward, from children being treated for cancer, to the omnipresent respiratory tract infection from RSV. This RSV infection seems to lead to most of the admissions, and plenty of sick wheezy babies. There is little that the hospital can do, and it is mostly supportive care while they get better themselves. 

My favourite patient on the ward at the moment is a 12 year old boy who, two days ago, started seeing hallucinations of snakes everywhere. I realise that my title sounds as though there are snakes hallucinating, but this is not the case (and I am not sure how you would be able to tell if it were). It was this boy who just started seeing snakes wherever he looked for no apparent reason. He has been in for a few days, and refuses to wear clothes as he is convinced there are snakes in them. As he is naked all the time, he has to stay in his room, but otherwise seems very lucid and collected. I had easy conversations with him, and we put jigsaws together and so on without any problems. He seems completely well, other than being able to point out these snakes he can see all the time. There always seem to be one or two present in a room at any time. He has had full toxicology screens for any drugs or substances he may have accidentally eaten, but everything is negative. There is no discernible cause for these hallucinations, though they are obviously very upsetting to him. At a loss of what to do, a referral has been made to the child psychiatrists to see what they think. I will keep you updated next week!

'Killing' a patient

Hi,


It's my last week on surgery, and I am now half way through the
rotations this year until my finals! A scary thought, as I certainly
don't feel as though I am anywhere near being ready for those exams -
but still not scary enough to start revising hard, sadly... As well as
the general surgery shenanigans I have been getting up to in the
previous weeks, this week I get to spend a day on the 'simulator', an
advanced electronic dummy that simulates medical problems and lets you
practice your diagnosis and treatment skills. This is something that
was mentioned to us at the university open day about 6 years ago, and
something I have been looking forward to since then!

Regarding the things I have been up to in surgery, I have kept on
doing ward rounds and ward jobs most mornings with the junior doctor,
who is really lovely. I also helped run a pre-op clinic where patients
were seen before their operation to check on their health, take blood
tests and so on. A very formulaic clinic where the same sort of
questions were asked to each patient, so I could be very useful here.
I also spend most afternoons in theatre, to make up for all the time I
have been missing over the last few weeks. Going to the theatre should
involve some acting talent or a lovely musical, but sadly in these
cases it involved cutting out gall bladders and a complicated
operation for pancreatitis where the necrotic 'rotten' pancreas was
removed by punching a hole all the way the stomach from the front,
using keyhole surgery, and draining out all the pus and dead tissue.
Watching the difference between the consultant and the registrar
operating was very interesting, as the difference in experience does
show. Both clearly perform safe and effective surgeries, only the
consultant does so much more quickly, and the movements he makes seem
a lot more confident and meaningful. It is almost beautiful to watch,
but I still don't want to be a surgeon and have to do that every day!

Onto the simulation training. As I said before, this was something I
have been looking forward to for ages. Imagine getting your 'own'
patient to try and diagnose and treat - its like being a real doctor
but with none of the responsibility if things go wrong. The mechanical
patient had a rising chest, pulses, heart sounds and opening moving
eyes, as well as veins which can be cannulated and lots more, meaning
loads of different diseases can be simulated, diagnosed and treated.

The way our session worked was there were four of us, and we were put
into two pairs. The idea was that one person would 'lead' a case,
while their partner assisted by doing things they asked them to do,
such as prescribing drugs and carrying out procedures such as taking
blood. In each scenario there was a trained nurse who would assist in
doing things a nurse would do, such as giving oxygen and administering
drugs prescribed. While all this was going on, the other two sat in a
different room, hidden by a one/two way mirror (why are these words
the same thing!), and watched what was going on to give feedback at
the end. The case I got was severe abdominal pain after binge drinking
in Ibiza, which I diagnosed as acute pancreatitis, (fortunate as I had
written an essay on this a week ago), initially giving fluids and
oxygen, then calling for a senior opinion. I did forget to do an ABG,
but other than that it all went very smoothly, though the 10-15
minutes the case took flew by in a whirl of activity. The excitement of
it, and how you get immersed in treating this very sick patient felt
quite real, and it makes me want to do acute medicine even more!

The case that I was there to assist my partner for did not go so
smoothly... This was a patient who had a severe respiratory infection
on top of a history of heavy smoking. She ordered all the correct
investigations and initial stabilisation of the patient was successful.
By this point we had both noticed that the patient was allergic to
penicillin, she by the wrist band on the patient and myself by
flicking through the 'admission notes'. Despite this, when working out
the CURB-65 score (a score used to see how severe pneumonia is), she
used the result to prescribe co-amoxiclav, which was an appropriate
antibiotic to give the patient. Other than the fact that they were
allergic to penicillin. Despite the fact that I knew about this
allergy, and had in fact only just written down on the drug chart that
the patient was allergic to penicillin, I went on and wrote up the
co-amoxiclav to be given, pretty much with the same pen stroke. Well,
the less said about this the better, but I can definitely say that
after making such a horrible mistake, that will stay in both of our
memories and we are very unlikely to make such a mistake again!
Despite having found out all the evidence (and knowing that we
shouldn't give co-amoxiclav, which all med students know is penicillin
based) we didn't link the two and gave it anyway. We were very lucky
it was only a dummy - but it does show how easy it is to make mistakes
in medicine, and the dire consequences that can come about if mistakes are made...

Brief orthopaedic stint

Hi,

Sorry for the brief late post this week, but things have been very hectic both in the hospital and socially, with no time to spare. I do realise I start most of my posts apologising for being short/rambly/late but that is just the British way - we love to apologise!

A pretty bitsy week this week, as it was a week of (poorly organised) orthopaedics, added to the fact that my car broke down part way through the rotation, leaving me stranded. That is all fixed now (at some expense) which is a blessing as a car really is a must at the moment! This week of orthopaedic surgery consisted of ward rounds, clinics and theatre time, much like my other rotations, only here they call them 'trauma' ward rounds, which makes them sound a lot more exciting. This, however, is a lie, and all they talk about during them is different eponymous operations, and bones. Lots and lots of bones. I noticed an interesting difference between some of the consultants though. One is very keen and does ward rounds himself twice a day, even when in theatre, while another does one a week, leaving the rest to the more junior members of staff. The former consultant tends to have two or three patients under his care at any time, as his are discharged very quickly, the other seems to have a dozen or so at the moment. This highlights the importance of consultant care when you are in hospital, and shows that they should do a lot fo ward rounds, as well as the fantastic work they do in theatre! 

One of the patients I was talking to on the ward had been sent back from a rehabilitation hospital with a more acute illness, but was begging to be allowed to stay in our (acute) ward rather than being sent back to rehabilitation. She claimed that the rehabilitation hospital was full of 'demented crazies' and she would go mad if sent back there. Currently not too sure what to do with her, as she cannot sit in her expensive acute hospital bed, stopping someone else from using it who has just broken a bone. Perhaps this case needs a consultant who comes around more than once a week.

That's all folks, next week perhaps I will be less busy... As you may have been able to tell, orthopaedics doesn't really interest me too much, and its harder to write about something you find less interesting!