Anonymous

I knew from the beginning that if I were to write a blog that included my experiences of medicine, and possibly some of my experiences with patients, it would need to be anonymous. I've mentioned this briefly before but it does need a post of its own to explain this.

Posts like this one, and one in my head about a patient I saw die, seem to require anonymity to protect the patient's identity as well as my own. Of course I do everything I can to protect the patient's identity anyway (changing identifiers etc), so that even the patient themself wouldn't necessarily recognise themself in my blog. But it's easier to ensure nobody recognises the patient if they don't already know which hospital, city or even area of the country the patient was seen in, or which medical student or doctor they saw.

There's also the issue that I don't particularly want my future patients to read this and know that it's their doctor, looking after them, who wrote it*. They could easily lose faith in me or not want me to be their doctor. It's not that I'm lying to them, but my doctor-face that I present professionally is confident and professional, and different to my blog-face and the things I share on here - my fears and failings, along with some potentially more contraversial thoughts.

I talked to a (non-medical) friend recently, and told them I had to re-take an exam and only narrowly passed a few others; their response was "I'm glad you're not my doctor" - I can see why. But once I have passed, I am deemed safe and competent enough to practice, and I'm no different to any other doctor. I hope my patients would see that, but some wouldn't and there's no need to tell them all and make an issue out of it.

I don't necessarily want all my colleagues to know that this is me, I don't want my consultants to know my fears and failings - if I did, I could tell them.

My posts about my medical school have sometimes been far from positive, but I don't want to bring them a bad reputation, just because I blog negatively about this medical school and people may not about others. And you never know, they could pull me up on things I've posted - it wouldn't be the first time a student had been reprimanded for things they'd put on the internet.

Since my posts about my family aren't always complimentary, I don't want them to see this blog and know that it's me, either.

If this blog weren't anonymous, I'd need to censor it and be more careful of what I wrote and how it could come back to bite me in the future.

I'm aware that other medical students don't always blog anonymously. The medstudent in the link implies that being proud of what she writes is part of why she doesn't blog anonymously. That's not to say I'm not proud of what I've written, I am to some extent (the mopey and despairing posts, less so), but I think the reasons for anonymity far outweigh the reasons against.

I hope that doesn't make me a coward - I don't think it does, but I'm sure it could be suggested.


If you know me personally and want to share this blog, feel free to but I'd prefer it if you don't blow my cover. Please do share it, it would be nice to have more people read it, but please don't share it in connection with my name or identifiers. This post has been a long time coming, and it's because of this bit that I haven't really felt able to share this blog with people I know until know. Apologies to people I know who've come here, you've got 34 posts to get through if you want to read this blog!

*If you don't know me, and you've read this, would you want me looking after you? Really?

I keep my visions to myself

Guess the song lyrics title at the bottom....

The night before last I dreamt that I'd found a patient, a rather mad lady who clearly needed some help, just outside a hospital (that looked a bit like Berlin Tegel airport somehow), but I couldn't get any phone signal to call an ambulance. So I had to take the patient into a hospital waiting room while I got some help, and I couldn't find any. I was upset that I couldn't help her. Somehow much later on someone pointed out that I could take her to Accident & Emergency, and I was so relieved, but also very worried at how I'd managed to forget that A&E existed....

Last night I dreamt there was a very special revision lecture happening. I spent a long time trying to find out who was giving it, trying to track them down, and find out where the revision lecture was. This somehow related to a wall hanging. But I couldn't find the lecture, or who the lecturer might be (I was looking amongst friends and acquaintances, rather than anyone who actually is a lecturer), and I got very stressed about it.

If I carry on like this the nights for the next few weeks will be very interesting. And stressful. Why I didn't feel at all able to help the patient in the first dream I don't know, maybe it reflects my lack of confidence. And maybe the fact that I was so desparately searching for the revision lecture reflects my lack of sel-motivation and need to have people teach me rather than me learning anything for myself.


I hope I get some more sleep than this in the next few weeks though, I'm going to need it.






Dreams, by Fleetwood Mac. Who are wonderful (and were not in anyway murdered or destroyed by Glee - in fact that episode reminded me how amazing Fleetwood Mac's music is and made me dig out my old CDs)

There are no laurels to rest on

Nice as it was to learn that I'd passed all of my recent exams, that silver lining had a cloud. Yesterday I was given my exact marks for the exams, and discovered that my two recent practical exams were very, very narrow passes. By 4 or 5 marks, and since the overall exam has over a thousand marks, that is tiny. I scraped through both exams, and it was very very close. Too close, there's no margin for error.

The day of the big exam was a "good day". I'd done a load of confidence building and affirmations, put my positive mindset on, and got in the best frame of mind. Nothing at all went wrong, and I was the best I could be for almost all the exam (although towards the end of the three hours I did get pretty tired, everyone does). So if my absolute best is to scrape through with the tiniest margin of error, what happens if I'm not at my absolute best next time? I might have a streaming cold, a headache, too much nerves, a grumpy examiner - anything that could lose me those 4 or 5 marks.

This has at least put the frighteners on and given me a considerable kick up the rear to get me back into revising and not sitting around beinig complacent, but for a good 24 hours it pushed me too far. I think there's a scale of:
complacent, unmotivated, not working enough ----to---- motivated, hard-working, slightly scared but in a healthy way -----to---- panicked, totally terrified, unable to work, so convinced of failure what's the point in working
and I went from the left end to the right end, completely bypassing the healthy middle. An email from a friend, an email from a mentor, and some time with the other re-takers later, I'm feeling a bit less chicken-heady (I am no longer running around with my head chopped off, which I was mentally doing this morning). I'm towards the right of the middle and it would be good to get even further towards the middle.

It would be easier if I knew what I was actually doing wrong in the exams and had some idea of what to improve, but no, that would be too easy. Medical school is a cryptic crossword. It's very frustrating to have a station which I thought went amazingly (patient/actor clearly liked me, I asked all the questions for the diagnosis and all the others to rule out a differential diagnosis, I answered the viva questions brilliantly - I am not a show-off, but I thought it was my best station of the day), the examiner gave largely positive feedback comments, with the only negative that I was "a little slow to get through all the points" - this does at least suggest that I got through all the points, to fail the station getting a little over 50% of the marks. How does that work?!

So in the absence of really having an idea of what to improve, I just need to spend the next three weeks becoming the most incredible doctor all-round that there could possibly be. I will dazzle and amaze all the examiners. A tall order but who knows what could happen...

And I will not spend the next three weeks wondering whether these horrendous results suggest that actually I'm not really ready to be a doctor, and it would be much safer for me and the general public if I did re-take the year, learn how to be a good doctor, and make a better attempt next year when I actually know something. That is not productive thinking. But it is tempting.


The above is yet another reason why this blog is anonymous. My patients don't really want to know how much I've failed, or how close I came to failing. At least, they don't want to know that and then continue to be treated by me. And I will want them to continue to be treated by me - it would be embarassing for me and problematic for the hospital if not. Much as medicine is trying to break with the tradition of paternalistic "the patient doesn't want to know X [often that they had cancer]", I feel it's appropriate here if only for my own peace of mind. I want my patients to have confidence in me. If I pass, I've passed and I am good enough to be their doctor. If they knew the numbers this may be less obvious.

Saving the world, one starfish at a time (or not)

Before I start, I am under no illusions - I am not saving the world!

This morning, as I went out early, I found a starfish on the pavement, just by the doorstep. A real starfish - the photo is at the bottom. It looked wet and it seemed reasonable to think it might still be alive. I was amazed and wondered if the storm or rain last night had really been bad enough to pick up a starfish and carry it the 500m+ it would need to travel.... and rushed off to my appointment.
When I got back half an hour later, it was still there, so I took photos, and went to tell other half about it. He very sensibly pointed out that it was probably dropped there by a seagull (not as exciting as the idea of wether-induced flying starfish, but far more plausible). I dragged him out of bed and we hatched a plan to take it back to its home and put it in the sea.

I'll explain here that there is a sort of parable by which I'd like to live my life, commonly known as "the starfish story" or The Star Thrower, written by Loren Eiseley in 1969. It's been re-told many times in different ways, and I heard about it from my utterly uninspiring headteacher, who managed to inspire me with this - I can't remember anything else remotely inspirational or even interesting that he ever said.
The version I remember I think of as having a small boy as the thrower, others have an old man or a girl. The beach is covered in starfish which have been washed up after a storm. Someone, let's say a small boy, is walking along the beach, throwing starfish back into the sea, one by one. Someone else, I think an old man, walks up to him and says "why are you doing this? there are thousands of starfish here, you can't possibly make a difference". The boy picks up another starfish and throws it, saying "I made a difference to that one".

It's such a simple, beautiful story, and although I don't think of it often, it's stayed with me over the years. I understood the message to be: you don't have to change the whole world, but you can make a difference to someone, or even a few people. Even if you make a difference only to a few, you have still made a difference, you can still change lives.

Others perceive it as meaning you should do what you believe in no matter the criticism. On looking it up just now, some versions have the old man deciding to join the boy in throwing the starfish, and more and more people join in, ending with the rather twee "all the starfish were saved" (personally I don't think saving all the starfish is the point, I think the point is that it is always worth making a difference, even if you can't make a difference for everyone; you can't save the world - saving all the starfish kind of is saving the world, and feels unrealistic). In that version, the message can be that you achieve something if you all work together, or if you can persuade everyone that it is worth making a difference.

I think this story is one of the things that spurs me on to do what I do, or what I'm going to do, be it medicine, volunteering with seriously ill children (more on that another time), campaigning, volunteering in schools... Each patient in my medical career could be a potential starfish. Not that they've all come to me to be saved, but that even if I can't do everything, I can still make a difference. To remind me of this, I have two beautiful pictures of starfish - one a birthday card from the other half some years ago, and one a sparkly postcard I bought last year while presenting my work at a conference abroad. I want to frame them both.

Back to this morning: given that this story really means something to me, I thought it would be a great idea to live in out (on a minute scale) myself, and take our doorstep starfish back to the sea. I didn't want to do it on my own - I thought I might need help (my intention was to carry it on a baking tray, I thought that way it might not dry out too much), I wanted it to document the starfish saving adventure photographically, and also I thought I would feel less silly and look less nuts if there were two of us poking and picking up a starfish and carrying it along. So I woke up the other half, got back in bed for a bit, waited for him to properly wake up and get dressed and got some plastic bags and an oven tray together, took other half outside with me.... only to find the starfish had gone. I don't know what happened. Maybe another seagull came along and thought it looked tasty. Maybe the first seagull wanted another go. Maybe some other people had the same idea and got there first, and the starfish is now happily floating away.... I'll never know. But I'm kind of kicking myself for not getting straight back outside and doing it myself. Specially if the seagulls got it.

I don't even know if it was still alive in the first place. But I'm still a bit sad about it - next time I'll seize the opportunity to throw a starfish when I see it, not half an hour later.

However, the positives: I saw a starfish! I never even knew they lived in this country.
In this time of considerable stress about exams, whether I'm good enough to pass, whether I'm good enough to be a doctor, whether I even really want to be a junior doctor with the stress and responsibility and total lack of confidence in my non-existent abilities that that involves, it was nice to be reminded of a reason why I came here in the first place - to make a difference, even if only to a few starfish out of thousands. That I can be that difference, and that it's worth it even if you can't save the world.

To have a real starfish to remind my of all this, to make me keep going - maybe that starfish was on my doorstep for a reason. I don't believe in fate - that would have been a nice explanation. But sometimes things happen for a reason, and today's starfish could have been there to rejuvenate and encourage me, to remind me to keep going. So I will.

[I realise this post could give away where I am, and therefore which medical school I'm at. And this is supposedly an anonymous blog. Please note I am not necessarily at home, or not necessarily at the place where I study - I might have gone away somewhere. Or be staying with family. You never know - make no assumptions.]

Dignity

Today I was writing notes on practical procedures, for practical exam revision. Specifically, I was writing about male catheterisation, which is a complicated process, so I made a nice step-by-step flow-chart.

One of my flow-chart boxes said simply "expose patient, maintain dignity". That's all it needed to say for th purposes of my notes, but it struck me how unrealistic that is; if it were as easy as just writing it in a flow-chart box and it were magically done, all hospital patients would be wonderfully dignified. Even whilst being catheterised (I've been catheterised; it is an unpleasant and rather undignified procedure, and I know that even without full recollection if it - I was still woozy from the general anaesthetic).

I love the idea that one could just mentally note "maintain dignity" and that would be all it took. It's so far from the truth. In all honesty, I don't even know how to maintain someone's dignity, particularly when they're being catheterised. I find it especially difficult with old people, more so when dementia is a feature (that's another post for another time). Being professional I'm sure helps, but there's more to it than that.

And I certainly don't know how to maintain it since when going over my notes I discovered I had forgotten that vital step "cover patient with sterile drape" - sheet with small hole for penis to protrude onto sterile field is going to provide somewhat more dignity than general genital exposure. Woops. The sheet is in the catheter pack, so it's unlikely I'd forget when I'm actually trying to do it.

I also forgot to mention the essential step of "reposition foreskin" - if the foreskin is retracted for a long period of time, scarring and serious damage can result. I should be able to do this in practice; the first time I observed a male catheterisation, the doctor had forgotten to do this and I reminded them, so I should be ok (as should the patient's penis).

For now, all my brief notes can really include is the simple "maintain dignity", but at least it will serve as a reminder that in practice, this is always something to consider. It will remind me to think about the patient's dignity, even if achieving it is a task that seems mysterious, difficult, and at times, impossible.

Communication - dilemma and success

Not long ago, I took an extensive history in oncology from a man who completely reminded me of my other half's dad. It was uncanny.
From thoroughly taking the piss for calculating his age from his date of birth embarassingly wrong, and his little jokes throughout, to the way he put down his wife whenever she tried to chime in and add to the history. Admittedly, some of her additions were irrelevant, but some were likely to have been useful, and either way, if you're going to build a rapport with the patient, you need to consider the accompanying relatives within that; it's no good building a great relationship with a patient and ignoring the relative sat in the corner.

It brought me on to a dilemma - how to encourage the wife to contribute, without publicly contradicting the patient telling her to shut up? Openly contradicting him (eg, "no, it's fine, that's [what wife just said] a useful thing to know"] could be detrimental to any rapport that I was building with him, but at the same time ignoring his comments firstly worsens any rapport with the wife, and secondly may prevent her from chipping in with more vital information for the history.
I also need to recognise my own innate "don't talk to her like that!" reaction which would automatically favour the encouraging the wife/contradicting him response, even if that isn't overall the most appropriate. Keep personal feelings and reactions in check! (more on that another day)

Probably a mountain out of a molehill, but I like examining the minutiae of communication. Whether that's productive or not is a different matter.

An achievement that I was a bit proud of - during my time with this patient, I learnt that he didn't want chemotherapy, or was at least very wary of it. We discussed why (a friend's experience) and we discussed that chemotherapy isn't just one drug, but many different drugs, and different people get different types of chemotherapy, with different side effects. That felt like a good discussion, he seemed reassured.
Of course, I passed this on to the oncologist discussing the patient's treatment plan with him. I was a bit disappointed that oncologist didn't take it on board and went straight in with "we will give you chemotherapy and it will be like this, fait accompli". No mention of "I heard you had some concerns about chemotherapy..." Oh well, tried my best!

Said oncologist was at a presentation in which a student discussed burn-out in doctors in oncology. Having a good relationship with your patients is a risk factor for burn-out, apparently (though I did meet a wonderful palliative care lady who explained why she thought the complete opposite was true). I wonder if oncologist already knew this, and was putting it in practice with my patient...

Just another occasion on which I wonder why all the extensive communication models and doctor-patient relationship psychology that came up in general practice theory is restricted to general practice. Surely it should be universal?!

All in all though, it was a good learning experience, boosted my confidence, and I build a great rapport, despite the patient's put-downs grating me.