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 I was happy for a day or two, before all the offers were withdrawn, and the tests remarked, before the offers are made again come the 8th (Friday).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! 

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!)