Like a little piece of charcoal

I woke up on Monday with so much dread for the week ahead and the work required that it suddenly came to as I was lying in bed: I am burnt out. On the one hand, that's horrible and means that I have no energy to do any work at all. But on the other hand, it's greatly relieving. It means I'm not lazy and useless, it's not all my fault that I haven't done enough work, it's just that I've done so much work and been so stressed for the exams in January and May that I just don't have enough energy left to keep going.

It felt so good to put a name on how horrendous I've been feeling about this exam and having to work for it. Burnout is a recognised concept, and a friend of mine had it after the January exams. I contacted her on Monday and she gave me some advice, including: get away from everything, go for a run even if you don't like running (which I did, briefly), burnout usually means you've done enough work already (yes, I did enough work in May, but unfortunately not for this re-take), to go easy on yourself (definitely), and to make a list of all your achievements, to push you on through this last one. I like that list of achievements idea - I haven't done it, but I have been thinking a little more about good things I've done, and that this re-take is really just to put the cherry on the cake. Except you can't have the cake without the cherry on, it is essential.

I realised that if I don't have enough energy to keep working through this revision period to the exam (which I don't), then the solution is to use other people's energy. Leech off them to get me through it, and work with others.

Which is what I've been doing. The only self-directed work I've done alone all week is to listen to a few podcasts whilst out walking places. So far, so good. Boo for burnout, but massive hooray for recognising it and getting through it.

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.

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.

Mnemonics for pharmacology and therapeutics

There's been much discussion of mnemonics for drugs, and just in case other medical students ever come across this blog, I thought I'd post them here (you never know, it might increase traffic to the site). I can't claim authorship of any of these, I got them all from friends - some may have come directly from, or been modified from books.

Enzyme Inhibitors - SickFaces.com
Sodium Valproate (anti-epileptic, also used for bipolar disorder)
Isoniazid (used for TB)
Cimetidine (an H2 receptor blocker)
Ketoconazole & fluconazole (anti-fungals)

Fluoxetine (a selective serotonin reuptake inhibitor)
Alcohol - acute consumption & cigarettes
Cardiac failure and liver failure
Erythromycin & clarithromycin (macrolide antibiotics)
Sulphonamides (antibiotics)
.
Ciprofloxacin (a quinolone antibiotic, which can cause tendonitis and tendon rupture)
Omeprazole (a proton-pump inhibitor)
Metronidazole (antibiotic effective against anaerobes)

These all inhibit enzymes and therefore can increase the amount of a drug that is metabolised by the enzymes that are inhibited, as less of the drug is being metabolised. Therefore, these drugs will increase INR as they inhibit warfarin metabolism.

Apparently amiodarone and grapefruit can also go in this group (which is why patients on some medications are advised not to drink grapefruit juice), and also ritonavir, a protease inhibitor used for HIV. However ritonavir's enzyme inhibition is useful as it increases the amount of other HIV drugs, so is always given in combination with another HIV drug to "boost" it. 


Enzyme Inducers - Crap GPs (not very respectful to GPs I know, but they can't all be good, there must be some crap ones)
Carbamazepine (anti-epileptic)
Rifampicin (antibiotic, particuarly used for TB)
Alcohol - chronic consumption
Phenytoin (anti-epileptic)

Griseolfin (anti-fungal - I've never heard of it, apparently been largely replaced by terbinafine)
Phenobarbitone (old-style anti-epileptic, not commonly used, not first-line)
Sulphonylureas (anti-diabetic drugs, e.g. gliclazide) & St John's Wort (herbal remedy used for depression - available off the shelf in Boots even though it could dangerously interfere with lots of drugs... but I guess so can alcohol)

These all induce enzymes, so will decrease the amount of a drug, as the induced enzymes metabolise more of the drug. They will decrease the INR, possibly below the therapeutic level, as more warfarin is being metabolised.
Worth noting that carbamazepine and phenytoin induce the enzymes that they themselves are metabolised by, so they induce their own metabolism. I think this is why you have to gradually increase the dose of them, as the more they induce the enzymes, the less of the drug you have, so you have to increase the dose. But only up to a point - not sure why that is. Maybe there is a maximum amount that the enzymes can be induced, I don't know.


Drugs metabolised by cytochrome P450 - Cow Pats
Ciclosporin (affects the immune system, used post-transplant and for psoriasis), carbamazepine (anti-epileptic), citalopram (selective serotonin reuptake inhibitor, first-line treatment for depression)
Oral contraceptive pill (contraceptive - very important!)
Warfarin (anti-coagulant)

Phenytoin (anti-epileptic) and protease inhibitors (a type of HIV drug)
Acetylcholinesterase inhibitors (eg Donepezil, used for Alzheimer's disease)
Theophylline (used for severe asthma) and tacrolimus (immune modulator, used for eczema and psoriasis, I think)
Statins (used to decrease cholesterol, particularly LDL) and steroids (used for loads of things! Auto-immune and rheumatological conditions, for example)

The only problem with this one is that you have to remember there are three Cs, two Ps, two Ts, and two Ss, which isn't reflected in the Cow Pats mnemonic.
The inclusion of warfarin in this list reflects what I said above about other drugs affecting INR. Thyroxine also affects warfarin, but maybe not through enzymes and that's why it's not on these lists.
Phenytoin and carbamazepine here, reflect what I said about enzyme induction.
Protease inhibitors here, that's why their metabolism is inhibited by ritonavir, as above.

That's all the therapeutics mnemonics I have for now! Maybe I'll have more mnemonics for something another day. Note mNEmonic, not pneumonic as Podmedics and loads of others pronounce it - these memory aids have nothing to do with air or lungs!

Apologies to the non-medics for the boring nature of this post. Normal waffley service will resume soon. Though I do like the opportunity to write a blog that contributes to the amount of work I've done today!

Ouch... and breathe.

Wow, you could even smell the despair in that last post on Sunday, couldn't you? Apologies for that. I have picked myself up a bit since then.

I've been doing considerably better mentally, partly from attending revision lectures in which I actually understood what was going on (very reassuring) and even did ok in the questions they asked in the lectures, so all cannot be lost. I think the biggest difference by far was made by hearing how lots of other students are feeling as horrendous as I was. I'm not in this alone - that makes everything a lot better.
And if we are all filled with dread and terror and fear, that must be ok because we can't all fail, right? At least, none of my friends failed in January and they seemed about as nervous then as I was.
I've also done some bits of practising skills, and although I'm fully aware I need to be working on confidence, it's good to feel like I'm making a start at getting there. I just hope others are as intent on group practising as I am, I think that's the key.

Also spending time with other people helps, I think it leaves me alone with my thoughts less, which means less despair. Much of this week I've been hanging around with friends between lectures, and half of that has been spent working or practising or discussing revision but that's ok, because it's still with other people who have the same problems I do. Maybe not quite the same extent of procrastination, but definitely some.

Another helpful thing was making a tally chart spreadsheet thingy on Excel to mark of what work I've done, how I've done it (podcasts, books, questions etc), what areas I've worked on, which has the two benefits of being able to see how much I've done and feel good about it, and also to see which areas I need to do more work on. So today I have mostly focused on Infectious Diseases and that row in the chart will soon become nice and colourful. As will my infection knowledge, hopefully.

I decided on Monday that I needed to make an effort to do things to preserve sanity - exams and exam thoughts cannot take up all my brain time. So Monday I went for a bit of a run on the way to and from the supermarket, which felt really good (very much a bit of a run, not a proper run - I'm using the first week of CouchTo5K to help, but I only do it occasionally so haven't got past the first week!), watched an episode of Glee which is awesome. Yesterday I realised late that I hadn't done anything to maintain sanity, so we listened to the News Quiz in bed - I am a massive Radio 4 comedy fan. And today a friend came round which was really lovely; we ate together, and I worked while she and other half watched a film, then we all had ice cream, and we watched some exam revision videos together (she's a medic in the year below, so it;s useful for her too) so it was sociable and work at the same time. It gives me more incentive to get the work done if there's fun stuff to do and people to chat to one I've done it :)
 So I'm planning to do something vaguely sanity-maintaining each day. I hope that will prevent me going as up the wall with despair as I did on Sunday.

I should note, just because I'm doing better in myself, doesn't necessarily mean I'm doing more work. It doesn't seem to be that simple, unfortunately. Today has been pretty good though.