Merry Christmas

Hi,


My last week before Christmas holidays, so a merry Christmas and a Happy New Year you all (or a 'Happy Holidays', depending on which you prefer). The last term has been 16 weeks long, which seems like it has been quite long, given all the essays and the SJT that have had to slot into it as well, so I am looking forward to a nice relaxing Christmas holiday, though revision will have to start soon for finals. Finals are still a long way off, around late March, early April (I think, though I am not definite), but I am not sure my usual revision method will work out too well (cram fervently a week or two before) due to the large volume of facts that I should know but I don't. 

As for this week, it was my last week of my obstetrics and gynaecology rotation. We only have two weeks of this speciality in 5th year, as we have some experience during our 3rd year, and this is meant to just be a refresher. I have been trying to make the most of it, as I cannot remember a lot of my third year as it was so long ago! 

The best part of this week was finally getting a chance to practice my suturing skills on a real live patient. Those who read this relatively regularly will remember that I had lots of practice last week in tying knots (though I did spend most of my post last week complaining about the SJT... sorry about that...) This week I got to practice them for real in theatre, closing up holes in the abdomens of all patients who needed a laparoscopy. These holes only need a couple of stitches  as they are pretty small (large enough to put a small camera down for the keyhole surgery) but its still good 'real life' practice for me. The gynaecological consultant is fantastic in trying to get me as involved as possible, and the team are great fun as well. I can see the appeal of being a surgeon. You do your work in the theatre, which you hopefully enjoy, then you get to go to the staff room and relax for half an hour or more while the patient is taken away, the new one is prepared and sorted out by the anaesthetist, and then you come back and operate again. Quite a relaxed job! 

I do have a scare in one of the theatres, though. I am late to one of the later operations, as I am answering a bleep for one of the registrars, which means I don't know why the patient is having this operation. I am asked to hold something for one of the more junior doctors, as he has to leave, and warned to be careful in case I damage the uterus. Not too sure how careful I need to be, I try and treat it like paper until he returns. Later on, they are talking about a ruptured uterus, and passing dye in through the cervix to watch it leak out into the abdomen. I am petrified that I have made a hole in this poor ladies uterus, but it turns out that she was being operated on for a suspected hole in the uterus, after having a hysteroscopy in Yemen (for some reason?!). I am very glad that this wasn't me, but I suppose this highlights the dangers of surgery and how you have to be careful with everything you do. It also highlights the dangers of having invasive tests done in an underdeveloped country.

While I had good experiences in theatre, I struggled to get much obstetrics experience at all. There are a lot of midwifery students at this hospital and, rightly so, they take precedence over me in getting involved in normal births. Because there were so many students, every time I went to the delivery suite, all women who were giving birth were already partnered with a midwifery student, and those who were due to come in had already had students assigned to them. I spent some time with the obstetrics doctor, though the doctors only tend to get involved when there are problems with labour, rather than in normal deliveries. I did leave my bleep number with the midwives, as they told me they would bleep me as soon as there was someone going into labour who didn't have a midwifery student assigned. I didn't get bleeped though. It is a shame, I agree that you don't really want more than one student in the room when there is a woman giving birth, and the midwifery students need a lot more experience in this than medical students do, but it would be nice to have just a little experience of normal births. I hope I don't run into someone in labour on a plane or something similar, or if I do, I hope there is a midwife present!

Anyway, have a lovely Christmas period, I am off now 'til Janurary, and I will keep you posted after that.

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. 

Catchup

Hi,

Ok, there is some need for some serious catchup, just for the purpose of continuity, before I promise to start my weekly blogging routine this weekend. Bear with me, so I can get into this.

Over the few months up to Christmas I have been on a reproductive rotation and a paediatric rotation. These were the first full time rotations I have been on in my medical training, and as such it would be best to start from these.

On the Reproductive rotation, I spent time doing Gynaecology and Obstetrics. This is quite a specialised subject, and this can be seen as a good or bad thing for one to start on. For one thing, it means there are (relativity) few complaints that a patient can have, meaning forming diagnoses and knowledge is less of an issue at a medical student level. When there are around 5 common Gynae diagnoses, it means you will know something about each one, and can take a good guess at which a patient is presenting with. There are obviously a lot more, much rarer, conditions, but as a 3rd year medical student these are less important. On a down side, if you are not considering Gynae as a career then perhaps the Gynae rotation is of less interest and use. I suppose its always useful being able to diagnose conditions and be aware of the Gynae differentials.

Anyway - In my time in Gynae I learnt to perform basic examinations, take a smear, take a Gynae centred history, learnt about the common Gynae complaints and got to assist in my first surgeries. The first surgery I assisted in was a hysterectomy for a large fibroid growth. This is basically a benign tumour in the uterus, and the patient was happy for the whole uterus to be removed so that it wouldn't grow back. The patient was friendly, easy to talk to and personable. I scrubbed in and got to assist in the operation, and then even more so when the assisting doctor got bleeped away. While it felt like a lot to me, I suppose I wasn't really doing much: Holding things, cutting thread with scissors, passing things to the surgeon and such. The surgery team works beautifully. Like a well oiled machine. There is often little talk in the theatre (other than occasional banter or music playing in the background) with the assisting doctor or theatre nurses passing things to the surgeon or assisting when they see that they are needed. While surgery does not appeal to me as a career (lacks a large element of the 'puzzle solving') this must be something fantastic to be the centre of. Anyway, the patient got better fast, and I saw her improve quickly in a few visits over the couple of days before she was discharged. Success! At least I didn't kill her.

Well I suppose I cannot talk about loads of cases in this 'summery' but needless to say the Gynae team were really nice and friendly, and provided the patients with first rate care. The only problem I saw was when I went to work with a surgeon, but the surgery list had been cancelled for the day. The patients and surgeon had not been told and all were very annoyed. Unfortunately the operations could not happen as there were not spare theatres, and they could not be carried out in the afternoon as the surgeon had a clinic of about 30 people to see then. The patients had been starved, bought into hospital and worried for no reason and the surgeon had wasted his time. Annoyance at the management came from this - an error in communication was the diagnosis.

We were taught to carry out intimate examinations by professionals trained to act as patients and teach us to perform them on themselves. An odd experience, but much much better than the fabled olden days of students practising such things on unconsented patients under anaesthesia!

The obstetrics rotation was very hands on. I got to assist in births and saw births from normal deliveries to water births to forceps aided deliveries to a C-section of twins.

I cannot say how amazing seeing a birth was, or how privileged I felt being accepted by all of the mums-to-be. Childbirth can be a scary time, and having them allow me to help out, under experienced supervision of course, was very generous. Fortunately all of the babies I saw were completely 'normal' and while some of the mums had problems with the delivery none of the babies were adversely affected. I saw one mum suffer from a Postpartum haemorrhage (PPH) which is where the uterus does not contract properly after the birth and all of the blood which would normally be supplying the baby (a lot) is not cut off as it should be and so pours out. A very scary time for me (and much more so for the mum and dad) as everyone was running around sorting things out and treating. I didn't know what to do with myself, so hid in a corner and noted down everything that happened for the notes. An important job, honest! Fortunately this, while not common, is a side effect that is well expected and drugs exist to make the uterus contract. Everything turned out fine!

I saw another very touching case, but it was somewhat unique, so I will not put it on here in case it in any way breaks confidentiality. Perhaps I can combine it with another some time later. Who knows.

In the obstetrics rotation, time was also spent in other smaller units, such as the Early Pregnancy Clinic, where women with problems during the pregnancy, such as bleeding, came to have a scan and bloods taken to see if they have miscarried or if their babies are fine. Very sad.

On the paediatric rotation I spent time trailing after doctors in hospitals, sitting in outpatient clinics and I also spent some time in the community, seeing children in nurseries and the such.

When in the hospital much of my time was spent observing. This was a shame, as I enjoy being hands on, but I suppose that children need the highest level of care and don't want to be scared by me. I heard that there was a clown that went around the hospital keeping the children amused. Unfortunatly I never got so see this, but wonder as to how much of a good idea this is - I am sure that if you have coulrophobia and are in a hospital this would be the last thing you would want to see. I did get to take a lot of histories from children in the assessment unit, while the doctors were busy elsewhere and present the patients back to the doctors. Hopefully saving the doctors time and getting the patients treated faster. Hopefully. When I was with a registrar we also got bleeped down to A&E for a child who was having real trouble breathing. Follow the ABC's and the child was put on oxygen. A suspected diagnosis of croup later and some inhaled steroids and the child was playing around on the floor. That's one good thing about children's hospitals, full of bright colours and toys!

Anyway - this sort of quick recovery really pulls me towards wanting to work in A&E. Making that sort of difference so quickly is really appealing, feeling like you are changing peoples lives every day is amazing. Well - keeping my options open but I will keep my eye on emergency medicine!

Time spent in outpatients involved seeing patients either before admission, or who needed to be seen by a specialist and had been referred by another professional, such as a GP. I did least here, mainly watching consultations. With a high volume of patients and little time common it meant there wasn't time for me to take a history and report it to the Dr, but I still got to learn about plenty of things from 'observing'. Saw some sad cases of abuse or suspected abuse, though, which I suppose is just something you have to get used to. Sitting in on clinics from general surgery to a clinic for premature babies who have lung problems due to being on a ventilator for so long gave a good variety and depth to the learning. Paeds is far broader than Gynae- and I think it is breadth that I am looking for in a medical career. Variety is the spice of life, after all! Who knows - early days, and I am not sure I have the patience to deal with children day in day out - too much bribery. I have a lot of respect for the patience needed to be a paediatrician!

In the community we saw children in clinic-like settings and visited nurseries. In the nursery I spent time with children with disabilities such as aspergers. What can I say? My course requires me to go and play games with children as a way to learn. I love my course.

Anyway, This post is very long, and pretty basic missing out a lot of the learning and interesting things that happened over those months, but its only a basic catch up. Sorry for the poor blogging style - it can only get better (though don't expect much any time soon - time limitations)!

I will be back at the weekend to talk about this last week.

Don't forget to smile.