Waiting game

Hi,

So my exams are finished, I got into the F1 and F2 placements I wanted in my top choices of hospital and I am sitting around waiting for my exam results. I think the exams went OK, there were some hard questions and some easy questions, but the most important question is whether there were enough easy questions / I did well enough in the hard questions / I messed up too many of the easy questions. I just want to know if I have managed to pass and can be Dr Internal Optimist!

There is nothing I want more at the moment than to be able to change the title of this blog to '

A WEEKLY BLOG FROM A UK JUNIOR DOCTOR

but before that happens I have to have passed my exams! Lots of nervous energy at the moment as I try and waste away the days before results day. It seems so unreal that I am (hopefully) almost at the end of the journey. I have wanted to be a doctor since I was in 6th form - around 16 years old - so this is about 8 years worth of ambition  and work. All of my A levels, exams and so on just lead up to this point, so very nervous indeed!

Either way, I will continue trying to use up the huge 'hole' left in my life where revision used to be by enjoying myself (so many hours in the day!) and I will keep you posted.

Wish me luck!

Ooooh, I'm half way there

But I am still, living on a prayer!

Sorry for the cheesy start... I am half way through my final examinations and the 'revision madness', combined with the relatively small revision play list has got to my head. I though I would 'give it a shot' at putting song lyrics as an introduction. Don't worry; it won't happen again ;)

Anyway, trying to work hard at the moment to finish off the final exams, but I am finding it tough to keep focussed (but not as tough as 'working the diner all day'...) It seems as though I have been working hard for far too long, and the poor brain is getting fatigued! Just need to keep focussed, will all be over by next Wednesday... 'one way or another'...

Exams so far have gone OK. There have been some hard questions and some difficult moments in clinical examinations, but there have also been stations/questions which I have done really well in. I just hope that the goods outweigh the bads! I have one more knowledge (written) test and one more clinical examination (where you are assessed on taking histories/performing examinations) left, so I am actually over half way there, but then that isn't nearly as catchy as a song...

Most of this month has involved me holing myself up in my room (or my ivory tower if you prefer), avoiding having any fun with my flat mates and working at cramming as many facts into my brain as possible, so I can regurgitate them on demand. Not living with other medical students this year is both a blessing and a curse. It makes it a lot harder to practice clinical examinations and histories, as they don't really want to/know how to pretend to have certain conditions for me to practice on. On the positive side, it leads to a much more relaxed atmosphere as around exam time, if the whole house is medical students worrying about the same exams, it feels much more stressful, and people mentioning some condition you cannot remember off the cuff while cooking dinner (those delta waves in Wolff–Parkinson–White syndrome) leads to more stress when you feel as though you don't know as much as your compatriots. This year I have been pretty removed from all that stress, but conversely I don't know if I am learning enough/too much! My thought process has always been that you don't (usually) regret working too much for an exam, but you are far more likely to wish you had worked harder, so I may as well work hard and hope for the best!

As for exams, things are going OK. I have had a few mistakes, most embarrassingly being very sure about a diagnosis of squamous cell carcinoma (SCC) in one of my clinical exams, after taking a history from, and examining, a patient with a prosthetic lesion. It had been created by some kind of skin putty moulage technique, and looked (very similar to) the picture below, but with a darker centre. I described it as below, with the central ulceration, and assured the examiner the most likely diagnosis was SCC

A 'classic' SCC lesion - and I swear the moulage looked just like this!

At the end I formulated my management plan, referral to dermatologist, etc and then for the further questions I was told that the dermatologist thought it was a melanoma, and I had to talk about the management of that condition instead. Below is a picture of a melanoma:

Melanoma from good ol' Wikipedia 

They don't really look very similar at all. I am not too sure what they were hoping for with the moulage, but I hope I wasn't penalised. I think that the paint that I identified as the 'central ulcer' was in fact the melanoma, and the raised edge around it must have been some kind of irregular border. Other people seemed to get it right, though, so perhaps it is just me! Perhaps the lesson here is not to be too certain about anything :P

Hopefully small mistakes like this will not lead to me failing the station, as you can only fail a few stations before failing the exam! I did pretty well across the rest of the examination, so hopefully  I will still pass. I finish my exams next Wednesday, AND find out my job allocation for next year on the same day. Hopefully it is going to be a really good day!

Just need to focus on doing well in the next two exams, so I can pass my exams, and be a (hopefully) brilliant doctor next year!

Final week of rotation as a medical student?

Hi,

Firstly, sorry for the late post. I have always tried to post Sundays, this has crept to Mondays and Tuesdays, and now suddenly we are on Wednesday night. its not because I don't care, its just that I am a little busy at the moment, and keep managing to do something else instead! 

It has been a long journey, but the last week was (hopefully) my last week of rotation as a medical student. I have a few weeks of revision ahead of me (hence why I am so busy at the moment), and then my final exams. After these (apart from being very relieved that they are over), I will have a little more hospital time, before (hopefully) starting work as a doctor! Crazy, but all very reliant on me passing these exams. I have always been a 'crammer' before, loving to cram up on information the week before a test, but now there seems to be too much information for this, so I am trying to get rolling earlier, so I don't fail. 

Other than revision, there has been this fiasco with the SJT test. I was placed in my first choice of region with a pretty high score, which was nice as it is a relatively competitive region to get into. I was happy for a day or two, before all the offers were withdrawn, and the tests remarked, before the offers are made again come the 8th (Friday). I am not too worried about my mark, as it was well above the borderline, but if I was on the borderline (either of just getting into my choice, or just missing out) I would be stuck to the news on this at the moment. As it is, I am watching it closely, but more out of an attempt at procrastination. Hopefully I will stay where I was last put, though!

In my last week of medical student rotations, I had some fantastic consultations. I was left morning and afternoon consultation slots most days, meaning I saw about 10-15 people a day on average, a lot less than a real GP, but similar, in that the patients coming in could have had anything wrong with them. I saw some pretty strange situations, such as the middle aged woman who had come in with her children to find out what she could do about her husband's addiction. This wasn't an addiction to gambling, drinking or smoking as you might think, rather an addiction to the Facebook game 'FarmVille', which had taken over his life, causing him to be fired from work. There was also an interesting case of a shrinking lady, who was about 80, but had shrunk down to 4 foot something due to hyperparathyroidism, meaning a hormone which released calcium from her bones was too high, causing her spine to crush down and for her to shrink. Strangely enough, the treatment for this was to put her on an analogue of parathyroid hormone (a drug that does the same as the hormone causing the problem) which was meant to solve the problem. Whether it does this by creating positive feedback, and thus lowering the parathyroid hormone produced, or whether it had some other effect on the bones, making them stronger, I am not sure. I will look it up; I am clearly still a long way away from finals proficiency! 


The highlight of this week, and perhaps the highlight of my medical education to date was a fantastic consultation that I had on Friday, my last day. The patient was a man who hadn't been seen by the GP for many years, but came in with severe depression. He wasn't someone who used doctors much, but had been persuaded to come in by his son. He started the consultation saying he wasn't too sure why he had come in, as he wasn't interested in any of our 'pills or potions'. As I have said before, I have half hour appointments with patients (because I am much less efficient than a real doctor), and this appointment was before my lunch break, so I had even more time. I ended up talking with him about his issues for a good hour and a half, something that a GP wouldn't be able to do at all. Most of the issues were not solvable by me or a doctor at all, issues such as unemployment, problems with the family, and so on. I will not go into any detail because of confidentiality, but I think he ha every right to be depressed. I ran a PHQ-9 questionnaire by him (used to assess severity of depression), and he scored 23/27, putting him as severely depressed. In the end, I explained what we could do to help him, mainly being medication, and talked about the Citizens Advice Bureau, which could help him with more tangible things such as accommodation. Many of his problems were coming from having such low mood and energy that he couldn't face doing anything in life, which means his life got worse, making him more upset. I talked about the benefits of SSRI drugs in this situation, in that they would provide a temporary 'crutch' for his mind (like a plaster cast for a broken bone), picking him back towards normal, meaning he could start sorting out his life, and get on top of these feelings. He was exceptionally grateful for my time and talking to him about it, saying that it had helped a great deal, and was keen on trying the medication as it sounded like the right route to take. This had all gone on without a doctor, so I called in the GP to double check what I thought and to prescribe the medication. The GP was very pleased with how I had done, and happy to prescribe. The patient was very thankful to me, and when I was arranging a follow up appointment in two weeks (as protocol) asked if he could see me, as I had been so helpful. What a reward, having someone want to see you over all of the actual doctors at the surgery. Sadly, as it was my last day, this wasn't possible, but it was so rewarding to have someone want to come back and see me. That must be one of the most rewarding things to have as a general practitioner; to have patients trust you with their health, and want to see you over other medical professionals.

Anyway, that was a fantastic consultation, and while only possible because of my long consultation times and free lunch break, it felt as though I could really offer something to the patient and the GP surgery in all. My very last patient was relatively simple, and the GP didn't even bother coming into see them when I presented them to her in her room. As they didn't need any drugs prescribed (or so I had decided) she just said that that all sounded fine, and I could sort it out. They were simpler than the gentleman in the previous paragraph, but this felt like a big step as well; I was seeing patients, deciding on a diagnosis and treatment, then initiating it all on my own. I am so excited about later this year when I (hopefully) get to do this myself at hospitals, but very scared about it as well. Such responsibility...

Anyway, posts may be less frequent and less wordy for the next few weeks, you don't want to hear about my revision after all! But I will try and keep these experiences in sight as I slog to cram my head full of (seemingly inane) medical conditions such as Buerger's disease, or Ehlers–Danlos syndrome. I really want to be a doctor! 

Rewards

Hi,


A good week, though busyness has lead to a slightly late posting again. Cannot win them all! I pick up on some 'hints' during one consultation with a woman, organising a follow up consultation to talk about her concerns, which is very rewarding (giving me a taste of being someone's GP), and I pass on some of the Viagra tips I had learnt a few weeks ago. The latter patient is really impressed with my knowledge of how to 'play the game' and tells me I will make a brilliant GP. I have talked about this before; it is funny how just regurgitating information to a patient which you learnt a few days ago can make you seem so smart. I guess that most of medicine is just remembering and regurgitating information (such as how to treat a heart attack / best blood pressure pills to prescribe in a 50 year old diabetic), until you turn onto research, which is far more science than medicine anyway. Still, its nice to be complimented and have someone think you are good and respect you, even if it is not earned!

The stark reality of me medical knowledge. Fortunately 6 years at medical school has taught me to pretend I know what I am talking about.

As for this lady who I called back, she first presented on Tuesday with what she thought was a hernia coming through an old C-section scar. She has had a number of hernias in the past in similar locations, which have required surgery, but on examination I couldn't see anything hernia-like at all. I thought this was a little strange, given the fact that she has had hernias before, so should know what they will be like. I chatted a little more with her while I waited for the duty-GP to finish with his patient and come and check mine, (the duty GP always checks the patient I see to make sure that they are not dying or something horrific before I discharge them). She mentioned this being close to the anniversary of her daughter's death, and on further talking to her about it, she seemed very down about this. Wondering whether this might be the 'actual' reason for her coming to the doctor, I asked her if she wanted to come back on Thursday and talk to me a little more about this, and she happily accepted, though seemed guilty that she would be wasting my time. 

Come Thursday, I was hoping that she would book in for the appointment, and she did! I ended up talking with her for an hour; she was severely depressed, scoring 21/27 on the PHQ-9 (a GP style depression screen). She was worried about so much, her home situation, her daughter's anniversary, someone who had abused one of her other children but had now developed MS, meaning she didn't feel able to go to the police about the situation, there was so much bottled up. Giving her a chance to talk about it all openly, and have a cry, really seemed to help. We talked about her coping mechanisms, and how helpful she found the Samaritains, and ended up increasing the dose of her citalopram (an anti-depressant). At the end, she was so grateful and thankful, saying what a difference I had made. It felt really good, the fact that I had spotted that this lady was unhappy, called her back for a chat, and helped ehr out, though perhaps only a minor amount. This must be the appeal of being someone's GP. You know them well, you are there for them when they are upset, and you can bring them back to help them with any other problems they have, rather than just treating the organ you specialise in in hospital medicine. This really is holistic medicine, something my medical school harped on about all the time in lower years, but I actually like it! If being a GP is like this all the time, I really wouldn't mind it at all. Before this rotation, GP was pretty much considered as a no-no for career, but now I thinkl its well worth considering. I wouldn't say that it has captured my heart, but it would be silly to rule it out when I love aspects like this. Perhaps I will try and get a GP rotation in my F2, and give it a real go.

GP specialism

Hi,


A very quick, and late, update this week. I spent the weekend in Paris at a student sports competition, which was a lot of fun, but has shifted everything along a bit, meaning I now have lots of work for my essays, and late revision to get on top of. It might not have been the best idea going, with regards to my studies, but was so much fun, our team did well, and a good 'last chance' at some university sport before I am not a student any more! As long as I still pass my finals it is definitely worth it!

The last week has been a bit of a mish-mash to be honest. I am still on my GP rotation, and have done a number of different things this week, as well as the 'standard' consultations with patients. The most exciting of these was spending some time with one of the GP partners who ran a substance misuse service. As the GP surgery is in a very rural area, the people who are addicted to substances such as heroin cannot get to city centres every day or week, so the treatments such as methadone are prescribed and given here. This lead to a number of interesting conversations and some very exciting characters; all made more exciting by the fact that this GP's partners hated these patients and refused to have anything to do with the clinic. Being in a relatively well off rural area, the GPs and the patients didn't seem to have much in common with these 'drug addicts', though the patients did say that they were more than used to getting 'snooty looks'... One of them had replaced his heroin addiction with the gym, and exercised for 3 hours every single day - meaning he looked very healthy indeed. He said 'I am a  addictive person, I need to be addicted to something. Much better that it is exercise than heroin'. 

I love that, as a GP, you can do so much. I also spent some time in an ENT surgery run by one of the other GPs this week, where he was performing minor procedures on ears. If you want, you have a lot of scope for specialisation as a general practitioner. I don't think I would mind working in that sort of environment at all, as long as I had the options to specialise in things that interested me. It would make seeing the endless colds and ear infections much more bearable!