Viagra tips

Hi,

I am now starting a GP rotation, my last rotation ever as a medical student (I really hope!). I have this GP rotation for one month, then a month of revision lectures, then my finals. A scary thought, though I really do hope that this is my final medical-student rotation (as otherwise I would be re-doing the whole year...) This GP rotation seems good though, with a lot of chance to run my own clinics and talk with patients. This is good, in that it gets me ready for all the patient-contact parts of my finals, but bad in that it takes up a lot of my time, meaning no real time for revision. The GP practice is about 45 minutes drive away from my home, and I am usually in from 9 'til about 5.30. It is like having a full time job, but without getting paid!

Because I am spending some time in the GP, it means I get to see a lot of patients. In the first few days I spent time with several of the partners who run the practice, watching their consultations, and some sessions with some of the practice nurses. This GP surgery is right in the middle of the country, in a relatively affluent village, and the patients (and doctors) tend to be quite well off. The GP I spend much of my time with this week is very different to doctors I have met before. He is about 50 years old, but very much 'jack the lad', swearing a lot, and bantering a lot with his male patients, while flirting with the elderly females. This goes down surprisingly well, and his patients clearly love him. I am told that he transferred here a couple of years ago from a nearby (but not close) GP surgery, and over 2,000 patients transferred to follow him. This isn't common, and shows that this consultation style clearly works for him. He is still very much a country man, though, and was sad this Wednesday after having to shoot his pet sheep, as it was ill. 

Thinking about it, I wouldn't mind a pet sheep. I wonder what my flat-mates would say...

The GP surgery runs a cottage hospital, where they have a few beds and an X-ray machine, so they can admit patients who are mildly ill and treat them without needing to send them to a large, acute, impersonal hospital. This cottage hospital is run by GPs and nurses. This seems like a lovely idea, meaning patients get care from their own doctors, in a location which is much warmer and less rushed than an acute hospital, while not having to travel far from their own homes. If there is a medical emergency, however, an ambulance needs to be called to take the patient to a 'real' bigger hospital. I think this is good for the doctors, as well as being good for the patients, as it means that the GPs can still practice a little hospital medicine, and perform minor operations and investigations themselves. After this week of GP, I really don't think I would mind working as a GP at all! Seeing the same patients time and again seems lovely.

Towards the end of the week, I was allowed to run my own clinics. This meant that I was given a clinic which patient could choose to book into when they were calling up to make an appointment. The plus sides were that this created more slots, meaning more patients could be seen, and I had 30 minute appointments rather than the normal GP 10 minute ones, but the negative was that I need to check each person I see with a real doctor, to double check my diagnosis and management plan, and prescribe any medications (as I certainly cannot prescribe as a medical student!). I saw a good range of different people and conditions, successfully diagnosing and 'treating' some of the simpler ones, such as otitis media, and colds. I learnt a lot as well. I learnt that if a 12 year old doesn't want you to take her blood, there is nothing you can do to get it- and spent a difficult half an hour before we had to send her away to be calmed down by her mum. I also learnt something that some of my readers may find useful. While prescribing Viagra is a private prescription, meaning the patient has to pay the cost price of the drug (about £30 for 4-6 I think), this is the same price for all drug strengths. This means you pay £30 for several 25mg tablets, and £30 for several 100mg tablets. A trick that the GP taught me is you can prescribe the patient the 100mg tablets, and explain that these are far too strong anyway, so they can break them in half and get twice the 'use' out of them. A useful thing to remember if you need to go to the doctor for these sort of problems yourself!

The GP strongly advises patients not to buy Viagra online, as it usually doesn't do 'the job' as it hasn't got the correct active ingredients in it. Use the dose trick!

Soup kitchen

Hi,


This week was my final week on this psychiatry rotation, and looking at it in the 'bigger picture', perhaps my last ever psych rotation. This goes for all of the specialities I have done this year, as unless I choose to take a rotation in one of these specialities when I am a junior doctor (fingers crossed) or choose to specialise in that speciality, I will not do that speciality ever again! This is an extra-big deal for specialities like obstetrics, and psych, where most of the 'acute' conditions are dealt with by specialists. Not such a shame for obstetrics (I have seen things...), but I have really enjoyed psychiatry, and while I don't think its the speciality for me, its a shame to say goodbye.

This week, the main parts were spending a session in a soup kitchen (but not that one) for homeless people, and another 'simulator session' with a robotic mannequin. The 'simulator session' was a repeat of one which I had earlier this year, where a mechanical patient had a disease and you had to try and manage it appropriately  The patient was programmed to respond appropriately to certain interventions, meaning this is a good way for us to practice treating someone without risking killing the poor patient. Last time, we almost did this, by forgetting about an allergy to penicillin. This time, I like to think I have learnt a little, as this didn't happen. It is still a very exciting simulation, as you get caught up in the experience, giving orders to your other fellow 'doctor' and the nurse who is there to help you look after the patient. We had problems such as lots of blood coming out of the rectum, perforated bowels, asthma attacks and so on. Very exciting!

However, I am meant to be on a psych placement. Sometimes it doesn't really feel like that, as there is so much else planned into the weeks I end up everywhere. Even the psychiatric placements are not always very psychiatric, as you may be able to see from some of my previous weeks. This week, the best placement was at a soup kitchen. It was run by a charity (a church) for anyone, and gave out free breakfasts and lunches. It seemed that this service was heavily used by homeless people, but if I had known about this a few years ago, I could have got some good meals when my budget became a problem! About 50 people were fed breakfast, and then hung around 'til lunch, and I am told that this is a quiet day! There is clearly a great demand for this service, and between breakfast and lunch there was a jumble sale of warm clothing for the homeless people. Not everyone there was homeless, some people had houses sorted out, or hostels, but were still without money for food. There was no need for the people using the service to pay, but many contributed a small amount (50p or so) just to try and help out. I was there to help serve out the food and generally much in with the volunteers who ran the place, and they were all a lot of fun! The person who cooked all the meals was a chef who worked the evening/night shift at one of the restaurants, but came here each morning to cook lunch from food scavenged from supermarkets at its sell by date. He explained that the evening job was for his rent and food, whereas this morning volunteering was for 'him', and let him feel he was doing something useful. These sort of unsung heroes lurk everywhere!

I am not too sure why I was placed here as part of my medical rotation, as it certainly didn't have much medical stuff in it, but it was very interesting talking to the people turning up. If I had more time, I would like to volunteer somewhere like that, but I just don't have time to spare at the moment... Many of the people didn't really want to talk to me about their own social situation, but were happy to engage in a chat about other things such as the economy, or literature. Many of them were surprisingly well read! One of the people there had studied history with Gordon Brown at university, and created a reading list for me, which he wrote on an A4 sheet of paper. Sadly I lost this cycling home afterwards! Another person was talking to me about the opposite of fragile. I would have said that this was robust, but was quickly told that I was wrong. Fragile things break easily, robust things just last longer before breaking, so this is not the opposite. This man claimed that there was no real word for this, but the best explanation would be 'antifragile', meaning something that becomes stronger when stressed, rather than weaker and breaking. He had a number of good examples of this, but the one that best stuck in my mind was (of course) to do with medicine and science. 
A hypothesis is a fragile thing, and can easily be disproven. A more robust thing would be phenomenology, being the study of phenomenon. Much harder to prove something is wrong, unless you are measuring it correctly, but still not the opposite of fragile. Here, he claimed the opposite was evidence based medicine (something close to my heart). In EBM, the more you stress your hypothesis (lets say that defibrillation can restart the heart, and save a life), the stronger it gets, as it gains more evidence. Antifragile! (This Antifragile  book may have been on my 'reading list' - I am so sad I lost that!)

What is PC for midget?

Hi,


A pretty snowy week, as I am sure everyone else noticed, but it sadly messed up my week of rotations. I usually cycle to the close events, so I made some clinical placements (where I managed to accidentally insult a 'little person' - read on...). I did miss the placement I was most looking forward to this week, though, which was a 'forensic psychiatry' placement. It was run at a secure psychiatric hospital for criminals with psychiatric conditions. Sadly, it is a long way away from my medical school and house, and I couldn't drive there because of the snow. I was really looking forward to this placement, as I had been there one before in my third year. It was set in the grounds of an old asylum (very creepy and deserted looking) and the patients had been very interesting, so it would have been very interesting, and I could have got some cool looking pictures!

As I am in a bit of a rush (work, play, constantly late submitting my blog) I will just briefly talk about things. As usual! The 'little person' incident was the most embarrassing, and hence probably the most worthwhile talking about. I was helping out in a scheme for adults with learning difficulties, mental health issues, and such like, where they met several times a week to do things like art and cookery courses. This isn't very medical, but I was working with a social worker and it was a lot of fun, making paintings and collages and so on. I was working with a small group of people, making a collage to take back to my flat, while chatting to them about their problems. Very informal, but I think the main reason for this scheme is social. I was talking to a person with abnormal growth, meaning he was less than 4 foot high; he was telling me how he got a lot of insults because of his height, and I was asking him what the correct term was for a shorter person. [He told me he calls other shorter people midgets, but didn't think that was PC for me to use, so I should say 'little person' (which I think sounds a little bad), or shorter person. Anyway, during my talk he was telling me how he was very good at collages, and showed me a very large, A1 sized one that he had been doing over some weeks. He was telling me how the difficulty was in the size, and keeping it homogeneous, and I (for some reason) just blurted out "well, they do say bigger is better"... We had quite a good relationship by that point (before, not after) and I was not even thinking about his size when I said it, just about the mural... Needless to say it didn't go down all that well (though we did patch things up by the end). Very awkward. I won't be making that mistake again.

Famous actor suffering from dwarfism - Warwick Davis.

Mocks

Hi,


A new week in psychiatry, though ruined a little towards the end by the ubiquitous snow which meant I ended up having to cycle through a blizzard! This week started with a mock test (to prepare us for finals), and had a selection of clinical placements and lectures through the rest. Sadly, one of the clinical placements I was most looking forward to, a placement based around people with HIV who had psychiatric problems, was cancelled. I thought it would be very interesting, as some psychiatric problems lead to people having much higher risks of contracting HIV (such as hypersexuality in mania), while addictive problems such as intravenous drug use, which are also covered under the psychiatric remit, can also lead to higher rates of HIV. As well as psychiatric reasons for contracting HIV, HIV infection can itself lead to psychiatric problems, such as anxiety and depression (from having the illness) and HIV dementia. The breadth of possible cases here could have been very interesting, but I suppose I will never know.

The mock clinical examination we had at the start of this week was sold to us a good chance to practice some of our history taking and examination, to help us start to prepare for finals in a few months (Finals in only a few months... Oh god...) but I thought it was more of a chance for them to scare us witless into revising really hard, so they don't have to explain why so many people have failed. It consisted of a range of stations, and the feedback I got from them seemed to conflict. The consultant running the chest pain history station told me that, while I got in all of the relevant questions [things like shortness of breath, and family history of cardiac disease] (one of the few to do so!) -I was too abrupt, and needed to be more personal towards the patient. The next consultant, in a station where the patient was suffering from weight loss, told me that I was too 'chummy' with the patient and I needed to me more formal and direct. While this does show that I need to change the style I use for examinations (and towards patients) it also shows me how objective some of these exams are - as I was being the 'same' (as far as I could tell) for each of these. I suppose some consultants prefer a much more friendly approach, while others may want you to be more efficient. I am sure that, whatever they prefer, they won't fail you on what they think of your style. At least I hope so!

Other than in the exams, I also saw some patients this week in a visit to the secure ward in the regional psychiatric hospital. I have been here before, during my third year psychiatric placement, though I can hardly remember that far back! I number of keypad and camera-operator opened doors let you in in an airlock type fashion into a rather nice ward. It is a far cry from the images of asylums in film!

Nothing like this at all.

In there I have some interesting talks with patients, whose circumstances were quite unique, so I will not go into them too much in the interests of confidentiality. There was an undercover policeman who had become so guilty at his work he had become a serious suicide risk and had to be supervised 24 hours a day, and an immigrant from the eastern block who had been in this country for years before trying crack cocaine, becoming psychotically confused and throwing bread all over a M&S supermarket, after becoming convinced that the people were seagulls. Once admitted to hospital, this man had become involved in a number of fights with other residents of the psychiatric hospital, though when talking to him myself, I thought he seemed very measured and in control, and he seemed to have great 'insight' meaning that he now understood that he was ill, that the hallucinations were not real, and that he needed to take these medications. The synopsis? Don't try crack!

Drugs

Hi,


I'm back, after a nice relaxing Christmas, and ready for my last set of rotations as a medical student - an exciting (and very scary) thought! I am starting back on a 4 week psychiatry rotation, something that I haven't done since my 3rd year (3 years ago!). It looks to be a really interesting selection of things planned for me, mostly based in the community, but with some short stints in psychiatric hospitals. This week, I have to brave all of the introductory lectures, have a very interesting session in a 'Substance Misuse' clinic, have a few psychiatric clinics, and have to section a patient and admit them to a secure psychiatric hospital.

The introductory lectures were more interesting than normal, as the people running them had thought up engaging games to help 'teach' us about teamwork and so on. My favourite part of this was a game where they created four groups: one made of consultants, one mixed consultants and students, one of random students, and the final one of students who had chosen to work together. They had to each look at a complex picture and talk amongst each other to recreate it as perfectly as possible. The idea was to show how people take leadership roles, how teamwork is important and so on. This was all well and good, but the fun came from comparing the sketches done by the three teams with students in with the one which came from the consultant group. I am not sure if they were meant to do very well, as they are all used to working in teams, but their picture looked as though it had been drawn by a child who couldn't be bothered to play. Despite it being a grid-based-robot-like figure, they had just scrawled a shape onto it. Perhaps their brains are attuned to recognising difficult diagnoses, to the extent that their art skills have regressed to pre-primary levels.

Most people's pictures looked a bit like this

The consultant's image looked more like this

Well, I digress away from my clinical experiences. The best part of this week was attending a 'substance misuse' centre, where people who are addicted to various substances come to receive safe doses to help them stabilise their lives. This may mean giving them methadone every day (pending an alcohol breath test), or may mean giving them other medications such as benzodiazepines to keep their addiction in check. The thought behind providing these medications is that many of these people who are addicted to drugs spend much of the day trying to beg/steal money for those drugs, then trying to find a dealer, meet the dealer, take the drugs, and then starting the cycle all over again. As the people take the drugs as a coping mechanism for problems they have had in life, supplying the drugs in a safe environment means that they have a lot more time in their day to do things like train for a job, or look for housing. Once these problems such as education and housing are more stable, the person is less likely to need to rely on the drugs, and then you can look at getting the person off of them. Just trying to take away drugs doesn't work, as it is removing their coping mechanism, which they need for their difficult lives. Talking to patients, I heard some very upsetting stories about abusive childhoods, about losing loved ones and friends, and one person had his girlfriend stolen by a pimp who wanted her to be his prostitute, and was then kidnapped by this pimp, who tried to get money for more drugs by holding him ransom for over a month. I have had such a 'soft' and easy life, I cannot begin to imagine what some of these people have to go though. Its impossible to judge people for using coping mechanisms such as drugs and alcohol when you have no idea about the torment they have to go through in their lives.

As well as this enlightening trip to the substance misuse clinic, I spent some time in psychiatric outpatient clinics where I talked to a number of patients with different psychiatric complaints, such as schizophrenia and bipolar disorder. The most interesting part of the week came when my consultant and I were called to come straight to the hospital to assess someone who had been admitted through A&E who seemed very manic. This was a 40 year old Irish lady who had come across to Britain to look for some records. It was very hard to find out anything more on top of that, as she spoke very fast (pressured speech), and was very hard to follow (flight of ideas). As well as this, she was very dis-inhibited and tactile, and was trying to stroke me and kiss my hand while I talked to her. By calling around her current GP practice, we found she had a diagnosis of bipolar disorder (though she denied this) and usually took medication for it. She could have left the pills in Ireland, though I think she stopped taking them while over there, leading to her spontaneous trip to Britain. She was clearly very unwell (though I am sure some of the 'pressured speech' just came from her being Irish), and so was sectioned under Section 2 of the Mental Health Act to be assessed and hopefully taken back to Ireland as soon as possible for proper treatment. A very interesting experience for me, though she seemed so lovely and caring - I felt very guilty being part of the team who was keeping her in hospital when she just wanted to 'go outside and do roly-polys down the hills'.