The Calling

The pleasure of a physician is little, the gratitude of patients is rare, and even rarer is material reward, but these things will never deter the student who feels the call within him.”

  • Theodor Billroth (1829-94)

 

 

Gunners

 

Urban Dictionary – A person who is competitive,overly-ambitious and substantially exceeds minimum requirements. A gunner will compromise his/her peer relationships and/or reputation among peers in order to obtain recognition and praise from his/her superiors.

It’s good to be good…

It’s always good to want to improve your own ability, build upon your existing knowledge and broaden your knowledge base. Medicine is a continuously evolving subject that requires by law that you do the same. I’d be worried if I knew my doctor wasn’t at least trying a little bit to learn more about the subject they’d chosen for their career…

However, comparing yourself to others can be dangerous. When we go out in the world we put on our public face, our public clothes, and our public attitudes. We don’t reveal our inner fears, our problems, our weaknesses. And since everyone else is doing the exact same thing we don’t ever see theirs. This combination of caging away our own issues and not witnessing those of others gives us the false impression that they’re finding everything so much easier, or that they’re so much better off than we are. This is further perpetuated online, as Facebook and Instagram give the opportunity to sell yourself to the world as that perfectly happy, exciting and fulfilled individual that couldn’t possibly exist in real life. It’s not exactly a recipe for sound psychological well-being.

But there is a limit…

Medical schools rank their students. Presumably it’s intended as an incentive to work harder, as a higher rank apparently brings the tantalising promise of a better job, more research opportunities and greater respect. Maybe it produces better doctors, maybe it doesn’t. What it definitely does do is discourage students from helping each other out. The stakes are raised, forcing us to show that we’re not struggling, that we know the required information, that we can hack it in this apparently brutal world of medicine. People become so preoccupied with that centile rating that they will give up relationships with their peers in an attempt to make excruciatingly small gains over them, be that by hiding information or learning opportunities, or even misleading them deliberately in the hope of sabotaging this ‘competitor’ and boosting their own ranking.

WTF?

I once asked someone what topics were covered in a teaching session that I had missed through illness, and they said to me, “It’s your fault you weren’t there”Turns out it was the Krebs’ cycle…

I’ve also heard rumours of students sabotaging the computers/iPad available during OSCEs to disadvantage those yet to complete that station.

It’s crazy!

The qualities we want in our doctors are compassion, teamwork, communication and integrity. Healthcare is never done on an individual basis, it’s always a team of teams of teams, each with their own area of expertise and interest, cooperating and communicating to ensure the best outcome for the person that really matters most – the patient. You can only gain by communicating well with others. Either you find out something you didn’t know before, you deepen your own understanding of a subject, or you have that satisfying feeling of helping someone else understand something just a little bit better, and knowing that you’re helping their patients as a result.

So I ignore the rankings. Always have, always will. I don’t care if the person I’m talking to is going to score higher than me. In fact, I’m happy if they do. Why? Because I’m determined to be a good doctor – it’s what I’ve always wanted to be – so anyone scoring higher than me in the rankings has to be pretty good as well, and they might be looking after my Mum one day.

 

Don’t be that guy – help each other!

How I work

Deciding how to work

After more than fourteen years of school and six years of Medicine at University, you’d think I’d have figured out how I work best when it came to studying for exams. Surely after that many years of studying, cramming seemingly endless reams of information into my head for retrieval on the big day, I would know whether I was benefiting most from writing out notes, listening to lectures and podcasts, making flashcards, or reading the textbooks…

 

I didn’t.

 

This was a constant source of stress for me as each year I would begin the process of walking out into the lapping waters of bottomless information, and not have a clue as to how best to study. Should I try and write everything down? Type it out? Make flashcards? Just listen? Whichever tactic I tried soon became either unmanageable, tedious, or I simply didn’t think I was learning anything from the process. So what did I do?

I thought about what I do when I come to retrieving the information. That is, in exams, whenever I’m trying to remember answers from my brain and wondering why I couldn’t remember medical facts like I could with cat videos or insulting jokes, how was the information presented in my head. Was it remembering the page of notes? Remembering the lecturer’s voice? The diagram on the flashcard?

It turns out that there were three main ways that I was retrieving these facts:

  • Remembering answers to previous questions that were similar to the one in front of me
  • Recalling specific experiences I’d had on the wards
  • Diagrams that I’d drawn and re-drawn until I could do it by heart
  • Flashcards that I’d done so many times that I didn’t even have to try and remember them.

It was a very rare occasion that I would remember a piece of information from notes I’d written or textbooks I’d read. So I figured I’d stick to these four categories, and hope that my analysis wasn’t way off..

How I work now

  1. I spend as much time on the wards as possible. This is largely because final year is meant to be as much of an apprenticeship as possible; you’re learning how to do the job of those a year ahead of you, so you’ll benefit most from observing, trying (and failing) to do the same things. Your brain is very good at remembering experiences that it has because it has so many ways of programming the information; sights, sounds, smells, temperatures, emotions – think of a time you screwed something important up – bet you never had to revise that again!
  2. I make flashcards. This is largely a convenience thing as you can make one or two in a spare moment, and review them during quiet parts of the day. I use Anki, purely because it’s free on android and you have your cards with you wherever you go.
  3. Nearer the time, when exams are looming, I talk myself through a topic, while drawing out diagrams. I then use the books to check what I’ve missed, and add the information to the diagram. Then I store the diagram away until next time, and attempt to copy it perfectly. Repeat until smart.
  4. teach! You never know information properly until you can teach it to someone who knows nothing about it. If you can explain something simply to a friend or patient, then you truly understand a topic.

Find your own groove

Learning is incredibly personal, and everyone does it differently. Try different methods, see which you like, and more importantly, which ones seem to work, and focus on those, rather than spending time doing ineffective studying that bores you and doesn’t help your exam performance.

 

Good Luck!

 

 

 

The metaphor

Don’t take life too seriously – nobody gets out alive anyway…    

-many people, at varying points in time

 

I’m rather firmly of the opinion that there isn’t much to life other than surviving as long as you can, having kids if you want them, and spending as much of that time being as happy and kind as is humanly possible. As far as I can see, If you nail those things, you’re pretty much golden. You’re going to die at some point, *sniff* and the world is going to carry on as it was, drifting through the inky abyss, until everything explodes, collapses, and maybe starts again. (contentious)

 

 

Maybe you’ll come back as a duck or something.

 

I’m a complete sucker for the feel-good, motivational, ‘you-go-girl’ quotes that get banded around the internet. They’re often pretty quirky, and leave you with a quick, tingly feeling of motivation or sudden renewed faith in humanity.

Always do your best. What you plant now, you will harvest later – Og Mandino

Life is 10% what happens to you and 90% how you react to it – Charles R. Swindoll

Start where you are, do what you can, use what you have – Arthur Ashe

Other times they’re just crap.

I can’t see myself without pink lipstick. I can go without it for a couple days, but if there was no more pink lipstick in the world, I’d be useless. Seriously. – Nicki Minaj

 

 

Sometimes they have a really profound impact on me, and I actually try and learn something from them, such as – The Magical Bank metaphor…

It goes along the lines of:

  • Each morning you get £84000 thrown into your bank account
  • At the end of each day your account is wiped clean, and you start again the next day
  • The bank might crash at any point, and the game is over
  • Anything you don’t spend is lost, anything you buy you get to keep

Sounds awesome right?

Gives you a new perspective on the 84,000 seconds you wake up with each morning to spend how you please, knowing that any time you don’t use will be lost forever. If someone stole £300 from you, would you spend the remaining £83,700 trying to get them back for it? Probably not… So why spend the rest of the day fretting about something that can’t be changed, or someone that wasted your time? Surely you can’t afford it!

 

 

Don’t watch the clock. Do what it does, keep going – Sam Levenson

 

 

 

 

Breaking Bad (news)

If you’re going to have to tell someone bad news, and working in medicine, it’s going to happen at some point, there are right ways to do it, and wrong ones.

See if you can spot the correct ways to break difficult news to someone, and the incorrect ways:

ROUND 1 – Introduction

  • A quiet, private room, with no interruptions and enough time to build rapport 
  • On a bus, with snacks and a megaphone 
  • Introduce yourself, explain your role and why you’ve come to talk to the patient
  • Enter the room wearing a hooded cloak holding a scythe 
  • Check the identity of the patient on their notes, wristband, and verbally
  • Shout to the ward “Which one of you f***ers is Barry?”
  • Ask the patient if they would like a family member or friend present
  • Isolate the sick from the herd

Um… hi, I’m here to talk about your scan?

ROUND 2 – Patient’s understanding

This is more of a ‘single best answer’ type of round… pick your favourites

  • “Please could you tell me what you’ve been told so far?”
  • “I bet I know more than you”
  • “Let’s play…. Guess the tumour!”
  • “I’d like to know what your understanding is so far”
  • “How many fingers do you really need?”
  • “If your life were a movie, which incredibly sad song would you like to have playing right now?”

ROUND 3 – Giving the information

The aim of this round is to give information gently, but without false reassurance. Decide which of the following would help you achieve this aim:

  • Fire a warning shot – “I’m afraid I have some rather difficult news…”
  • “You’ll never guess what!”
  • Fire an actual shot
  • Divulge the necessary information clearly, in small chunks
  • Produce textbook of palliative care opened at ‘caring for the dying patient’ 
  • Let the patient guide the conversation through questions
  • Respond entirely in questions
  • Respond in braille
  • Watch their body language
  • Watch only their body
  • Make eye contact
  • Do not make eye contact
  • Do not break eye contact
  • Sit next to them in a relaxed but attentive pose
  • kneel
  • lie prone

ROUND 4 – Empathy

Congrats on getting this far, now we really up the stakes. Your job is to persuade the person opposite you that you care. You might actually care, in which case you have a storming advantage for this round, but in case you don’t, here are some possible tips and tricks. But pick wisely:

  • Positioning
    • Sit close to the patient
    • Sit in next room and shout at patient
    • Sit on patient
  • Voice
    • Whisper
    • Quiet but clear voice
    • Yoda
  • Physical contact
    • Hand touch
    • Lip hook
    • Trap squeeze
    • PR
  • Posture
    • Open and relaxed
    • Marine squat
    • Teenage slump
    • Downward dog
  • Encouraging their response
    • “I’d like you to know you can say anything you want”
    • “So……..coffee?”

ROUND 5 – Summarising


The final round! Which of the following do you feel is appropriate for concluding the discussion?

  • Understanding
    • Hand patient a leaflet with relevant information
    • Hand patient phone numbers of support groups and networks
    • Ask patient for their phone number
    • Hand patient a quiz on ‘what we’ve just learned’
    • “Do you have any questions at this stage?”
    • “It’s my lunch break, ciao”
  •  Follow up
    • Explain the next step, and the patient’s options at this time
    • Say what might happen, but who knows it’s a crazy world
    • Encourage patient to stay positive
    • Enquire about organ donation
  • Closing
    • Ask how they’re getting home
    • Ask if they still really need their home
    • Ask if you can have their watch
    • Determine when you will next meet
    • Shake hands
    • Fistbump

It should be fairly obvious which of these are the right way to go about a difficult discussion, but hopefully the wrong ones will make them easier to remember (scythe…probably not – introduce myself) and give you a bit of structure as to how to conduct one of these conversations.

GOLDEN RULE: stop talking. The patient is not going to hear a word you say. Their brain is full of panic and distress, there’s no space for anything else. When space becomes free, they’ll fill it by asking you questions. Answer these questions, and then let the silence wash over you, it’s strangely calming.

Good luck.

My OSCE top 5

OSCEs are interesting beasts. They are terrifying whilst simultaneously quite good fun, and I personally end up learning as much from doing the OSCE itself as I do revising for it in the first place.

One brand of OSCE station that comes up is Explaining and Communicating, in which one must demonstrates one’s prowess in the task of bringing a patient up to speed on a condition, treatment, test result etc. in as kind, clear and concise way as possible. You can’t drown them in information, but you have to tell them enough, and you can’t be overly reassuring but you equally don’t want to crush their spirit. So what’s the secret?

Practice. 


Not the answer people want to hear the night before an exam, but truly the only way to master a task this demanding is through experience, working out what works best for you and seeing how patients respond. However no amount of practice is going to help if you don’t have a good recipe in the first place, so here’s a summary of what should be done in any explaining station, if you want to be on the right track.

1. You’re a doctor


Or medical student. That means you have to:

  • do no harm
    • wash your hands
    • ensure you have the right paitent! 
    • don’t say anything that will unnecessarily upset your patient
    • protect vulnerable patients (eg children, abused partners, very ill patients)
  • respect the patient as an individual
    • give them accurate, relevant information
    • allow them to make their own decisions
  • do right by the patient
    • tell them what you would like to know in their position
  • try and help the patient
    • give options for treatments
    • give reassurance where appropriate
    • provide emotional support
    • ensure they always leave with a plan

Sometimes you may have to hurt the patient (giving bad news, venepuncture, reducing a fracture) but in these circumstances the others (try and help, do right by the patient) are of greater influence. Your job as a medical professional is to decide which are the most important in each situation, based on where the patient’s best interests lie. Clinical judgement. Fun.

2. What do they know already?


This bit is arguably the most useful for you as the explainer. Ask the patient what they’ve been told so far, or what they understand, and what they say will save you huge amounts of time, as you’ll then know:

  • at what level to pitch the information 
  • what they know, and so you don’t need to talk about
  • what bits they’re concerned about

The last one is important, because you might think you know what the salient information is in a particular consultation, but only the patient knows what they want to know about, and that’s why they’ve come to talk to you. So ask them and ye shall find.

3. Confidentiality is key

A doctor has a privileged position of being able to keep secrets. Patients should be able to discuss absolutely anything they like with the doctor without fear of embarrassment/repercussion. There are a very few cases where you are required by law to disseminate information to the relevant authorities (knife/gunshot wound (Police), epilepsy (DVLA) (make sure you tell patient to tell them first and say you’ll have to tell the authorities if they don’t) however the vast majority of the time, you should never ever ever share anything anyone has told you outside of the medical team working on the case. So in your explaining station, think:

  • Does this person need to know this information? 
    • (eg parent asking about their infants’s condition vs asking about adolescent’s condition)
  • Am I breaking confidentiality by revealing this?
  • Should I conduct this conversation with/without patient’s relative/partner/friend in the room?

4. Know your limits

Sometimes you won’t know the answer to their question. Don’t lie, don’t make something up, don’t say “I have no idea”, but say something useful, such as:

  • What I’ll do is print you out a leaflet with all the information that you can take home with you
  • There is fantastic information on the NHS/Patient websites 
  • I’ll double check what the current guidelines say and let you know

5. Listen


Half of the time in an OSCE you’re thinking only about what you’re going to say or do next. This is fine (to some extent) in a procedure or an examination, but in an explaining or history-taking station it’s a surefire way to get stuck. Remember:

  • The patient/actor has been given a list of answers
    • They have been given the important information that you need to elicit, so when they start telling you – actively listen to what they’re saying!
  • Thinking about what you’re going to do next can actively lead you astray
    • Particularly with history stations, you might be thinking “I have to ask about this” meanwhile the patient is telling you a symptom that completely changes your differential – listening and clarifying things they say (what type of pain/when is it worst/what does the discharge look like? will be much more likely to provide you with your answer)
  • If you’re stuck, ask them for help!
    • It’s a little more subtle than that, but saying something like ‘Is there anything else you think I should know about/Do you have any thoughts about what it might be?’ can get you out of hot water.

Of course each station will be different, and will require its own emphasis on explaining prognoses/addressing concerns etc but as long as you follow these 5 guides, you’re unlikely to do too badly.

As always – if you disagree or feel I’ve missed anything please comment!

The 1 minute rule

If something takes less than a minute, do it now.

 

I used to be absolutely terrible when it came to having a whole load of little jobs to do. I’d try and work out the best order to do things in to be productive, or write a list and work my way down it but it seemed so frustratingly endless. So I started using the one minute rule. If you’re part way through a task, and another one lands in your lap, either from an email, facebook post or housemate – and it is likely to take less than a minute to achieve, do it straight away.

The logic is that if you add it to the list of things to do, or try and work out when best to do it, you’re already spending nearly a minute just fretting about when to do it, so why not just get it done?

RTFQ


Read the full question

This is drilled into any student from a young age, and it never ceases to be true. Exam papers are minimalistic, they rarely contain any information that they don’t need (unless they’re testing your ability to sift through useless information…). This means that everything in the question is there for a reason, so analyse every bit


Eg. A 48 year old lady from Africa presents with…   


They’re not writing this for fun! This is saying ‘I want you to think about the risk factors for this age group and this nationality – use the information they’re giving you!

Keep the needle out of the flame


Don’t put a needle in inflamed tissue

This may sound obvious, but it applies all over the body. Needles hurt anyway, so sticking a needle into an infected or inflamed area is going to hurt a lot more, and risk spreading the infection. This applies to local anaesthetic, injection of botox into an overactive bladder, or injecting steroids into a painful joint.

The example of local anaesthetic:

Lidocaine doesn’t work well in an acidic inflamed environment, and the blood vessels in inflamed tissue are dilated to improve supply and drainage to the area, meaning the systemic spread is massively increase. Finally, the effective half life plummets as it all gets washed away. 

 

Follow me


Let the patient guide you

Searching for a diagnosis is like trying to find a certain room in a large building complex. The quickest and easiest way is to ask the person who knows where the rooms are and who has the keys to all the rooms.

This person is the patient.

Ask them where to go, and let them lead you. Don’t try and jump ahead, just follow them to the correct destination. If you start jumping, and thinking ‘I think this is pneumonia’, you’re essentially running ahead to a random room and asking ‘is it in here?’. Wait till the patient has told you everything, and see where you’ve ended up.

 

Burn, baby burn


My pre-OSCE hand wash

I get very nervous before exams, and I always have. I’ve been told it’s a normal response. Usually by the time the exam has started I’m alright, but the nerves before hand get very stressful. One thing that happens before OSCEs is my hands get really cold and clammy. Not only do I notice this, realise that it means I’m nervous, and get even more stressed out, but when I then go to shake a patient’s hand, it’s unpleasant for them and shows them that I’m nervous as well, and probably impacts on my global score. So I started a routine of finding a sink five or ten minutes beforehand and running my hands and wrists under the hottest water I can bear for about two minutes. It makes them go bright red, but forces them to vasodilate as well as warming them up directly. It might not make much of a difference come station #12, but it chills me out knowing my hands aren’t freezing cold.

 

Visualise success

 

There’s a big thing now about achieving success through visualisation. Sport, surgery, you name it, by visualising the task ahead, and thinking about how you might achieve it, react to obstacles and prepare in advance, you stand yourself in much better stead when the time comes. When reading through notes, picture yourself in a cubicle with a patient. What does the patient look like? What are they going to say/ask you? What are you going to do? How will you treat them? This way when the time comes, you’ll effectively have done it before, and will have a much more contextual understanding of the material, rather than abstract concepts on a sheet of paper.