On the Spot
I’m at that rather dubious stage of my medical education wherein friends and family will quite happily tell me about their various health woes in a manner expectant of a sensible answer. Sadly, I can no longer get away with the excuses that served me so well in the first three years of uni (“I haven’t done any clinical medicine yet”) or the more recent version (“I haven’t done that speciality yet”).
I don’t always try to avoid answering, because sometimes I think I can actually be of help. One of my friends had a relative who had been discharged from clinic with a letter explaining the diagnosis. However, because this letter was a letter to the GP in which the relative had been copied in, most of it was gobbledygook to them. The letter was chock full of medical terminology that they found completely undecipherable. It was thus extremely gratifying when I was able to just simply explain what everything meant, being a walking-talking medical dictionary in a way.
Sometimes though, my actual medical opinion is sought, and that’s when I get a little nervous about whether I’ll really be helping or hindering. As a doctor, you are accountable for your advice to patients (diagnosis or management) and what that actually means is becoming more clear. What’s also slightly unnerving is that, quite often, friends and relatives seem to put more weight in your words that those of their own doctor! The mix of someone you trust as a person who also has medical knowledge seems irresistible… For me, it took a while to understand why a friend would put so much faith in what I was saying, and once I realised this, I have tried to ensure that my advice wasn’t going to be a substitute for going to a specialist.
Having said that, I do want to help when asked. I want to be able to give comfort, to point friends and family in the right direction, to be useful. It also is nice to realise that my student loan is not going to waste… I guess what I find difficult is that I don’t feel qualified to give an opinion and so am scared I’m giving the wrong one. But when I’m a doctor, that’s not going to be good enough for my patients. Sure, it’s ok to be scared sometimes, and an element of self-doubt can be healthy, but the only way to gain that confidence, to feel qualified and deserving of patients' faith, is to be the best that I can be. It’s a long hard slog, but ultimately worth it if I know that what I say and do will be the best that I can do for my patients.
Why Do We Do It?
Every medical student must reach some crisis point in their training where they ask themselves “why am I doing this?” In my case, it’s usually precipitated by either a severe lack of solvency, someone I know jetting off to warmer climes, or having to learn microbiology.
At times like these, being a student feels like very hard work, and it helps to ask myself why I chose medicine in the first place and why I’m still here.
One of my housemates is a die-hard OB/GYN. From the tender age of 3 when she chastised the OB/GYN consultant for forgetting to take her blood pressure in a make-believe consultation, to her feverish planning of an OB/GYN elective, she has always known where she wants to be.
Yet there are students in my year who switched to medicine late in the decision process, people who were going to be linguists, lawyers, mathematicians, English literature students, art students… What changed their minds? Usually something practical, like job security, a good profession etc. A couple of my friends even said that they picked medicine for want of anything else to do!
Have their reasons changed? Would they pick medicine again? Most of my friends said that their reasons were still the same, and that, reassuringly, they’re glad they picked medicine. One of my friends said something especially interesting: “I had undervalued the idea of a profession.” That sentiment seems to encapsulate a lot of what medicine means to me now.
I never applied with the altruistic attitude of “helping people” (there are easier and less bankrupting ways to do that!); I applied because I loved human biology at school and wanted to learn more. Having a doctor mother, I thought I understood what being a doctor was. But even I underestimated how much of a lifestyle choice it is; being a doctor means something more than just going in to work everyday. It means being able to put my learning of the human body into useful practice, making a contribution to society and, with research, to knowledge. It represents the trust with which complete strangers entrust their health, their families, their confidence. It means working in a busy, ever changing environment, with lots of different people in different branches of medicine, learning and working together. And this is now what keeps me going.
So, why did I apply back then? To read medicine. Why would I apply now? To be a doctor.
The Excitement of Starting Clinical Medicine
This time last year, I was starting clinical medicine for the first time. Taking my first steps into a ward, not quite used to the prescribed chaos of day to day hospital medicine, everything a bit bewildering and wonderful. Over the past year, the "firsts"’ have become routine and the excitement wears off.
Which is why I’m so grateful for the arrival of the new first years. True, they have taken over the common room and filled in all the crosswords before I can get to them. But they also get excited about taking blood and watching appendectomies. It reminds me that, yes, what we see and do everyday is actually pretty cool. I was watching a partial lobectomy of a lung today, and the trainee nurse standing next to me whispered “this is amazing!” For a moment, I stopped trying to figure out management plans and just took a step back and thought, “yes, actually, wow!” It was nice -– to have that feeling of utter awe and amazement again.
The other thing is that I see reflected in the new first years the same worries that I had when I first started. Worried about how on earth I was ever going to get the hang of 5 different examinations, about when heart sounds would click (no pun intended) and sound more than just whooshing, and about hurting patients every time I touched them. And I realise how much more confident I am now with examinations and dealing with patients in general, after practicing on umpteen patients. It just goes to show how much we learn in that one year!
But what an insurmountable task it appeared to be at first… Because no matter how much I reassure my "children" in the first year that it will all come together before the exams, I am met with the same disbelief that I doled out to my "parents" in the year above when they told me the same thing. History certainly does repeat itself where medical students are concerned.
And in keeping with that, I realised something. I am half-way through my penultimate year. In 18 months, I’m going to qualify. By Christmas, I will have covered all major specialities except OB/GYN and peds. Theoretically, I should know enough to diagnose and formulate simple management plans for any adult male with a medical issue. Now that’s enough to give anyone palpitations.
Know Your Place?
In the hierarchy that is medicine, you enter at the bottom as a lowly medical student and attempt to make your way to the lofty heights as a consultant. Self-evident from the start, this unwritten hierarchy is followed by all. Which really makes life difficult if you feel the need to break it. This hierarchy is based on knowledge, with the presumption that your superiors will know more than you. And, by extension, are more right than you. But, just occasionally, that’s not the case, and then all the fun begins…
In one of our lectures, we were told an anecdote about a surgeon who was conducting a left nephrectomy. However, on the same day, a right nephrectomy had also been scheduled… you can guess what happens next. The anecdote goes that although the medical student observing that day thought that this was the wrong patient, he didn’t say anything. Maybe he wasn’t sure what was really going on. Maybe he wasn’t sure that this patient wasn’t the right nephrectomy patient –- it is, after all, often easier to doubt yourself than someone senior. Maybe he was just hoping someone else would say something?
Happily, most consultants I’ve come across treat their team as just that; management plans are formulated together with the flow of ideas and information going both ways. This is as much a teaching process as patient care, so there are advantages for all parties.
But as medical students, it can be hard to feel like you’re ever in a position where you can correct a senior. Maybe it’s because as students, we don’t feel qualified to do anything yet, never mind suggest to a senior that we think they might be wrong. Maybe it’s because in our current situation, where we don’t really have a job or our own patients, we don’t feel enough part of the team to say anything.
In this lecture, we discussed if there were possibly ways to deal with this issue, and the idea came up that being a medical student was positively advantageous. Asking the surgeon to talk through what he’s doing or, as one of my colleagues put it, “to express keen interest in the unusual approach” seems a fairly tactful way of doing things. After all, as a medical student, it’s practically our privilege to be a bit ignorant!
Left to our own devices, we medics can be pretty lousy conversationalists. We are those awful people who no-one wants to invite en masse to parties because we congregate by ourselves in a little corner and talk about things sane people try to avoid.
My non-medic friends in college used to jokingly ban all “medic-chat” from parties, claiming that it demonstrated that we had no lives outside medicine (probably true) and that it was boring (evidently a falsehood). It’s a sad fact of life that we medical students talk about virtually nothing else but medicine (occasionally, we talk about medical school). And it’s actually very hard to not talk about medicine even when talking to non-medics. Ironically, that’s often when I talk about medicine the most, probably because I spend so much time in medicine that I have lost confidence in my ability to hold a decent conversation in anything else when wrenched from that bubble. (My non-medic friends would remark that medicine doesn’t make for a decent conversation either.)
But I am a staunch defender of “medic-chat”. Irrespective of whether medicine is a fascinating topic of conversation or not (it is), we medics would not survive as a profession without it. We certainly wouldn’t get through med school without it.
The practice of medicine is all about teamwork; talking about our jobs outside when we’re not working is just one part of that. Shared experiences forge stronger professional relationships and camaraderie. After a tough/ disappointing/ hard/ long day at the hospital, talking to a fellow medic about it is often just what’s needed to help you deal with it and, more importantly, make you want to go back in there and do it all again.
But by far the most important part about "medic-chat" is that it’s with other medics -- people who understand what it’s like, both the good bits and the bad. In the hospital, so much of what we are privileged to hear, see, and do is unique. Some of it is downright traumatic, revealing humanity at its worst, its most vulnerable. Acting as each other’s counselors, we don’t judge if another medic is less that PC about something, we understand the little triumphs, and we sympathize with the failures.
There will always be times when medicine is the last thing I want to talk about. But, when the going gets tough and I just have to deal with what’s coming, it’s the medic-chat that will see me through.
Visiting a Private Hospital
Lucia Li -- No one likes hospitals. It’s not always a pleasant environment to work in, and the more I do clinical medicine, the more I want to avoid ever being an in-patient. But, no matter how much I might whine about our public hospitals, I don’t think I could have it any different, as I found out when I went to visit a private hospital.
The first thing I noticed was the car park. It was surrounded by beautifully manicured lawns and untrampled flower beds. And it was free. Which is kind of ironic, given that the cars filling it made the car park look like some sort of car showroom. My battered little Clio looked distinctly out of place.
Then you walk in through the big double doors (more flowers, this time in pots) and are greeted by a shiny wooden reception desk nestled in the corner of a cozy waiting room. Key features include patients who are better dressed and have thicker wallets than their doctors (though I did notice that our consultant wore a tie for this clinic), a (free) coffee machine dispensing drinkable coffee in china (not paper) cups, and carpet (of the tastefully coloured, hotel lobby variety). And the staff are uncharacteristically calm. Probably because they have a working coffee machine and feet stamping isn’t nearly as effective on soft carpets.
And then there’s the consultation rooms themselves. They had curtains! Which not only looked like they had been brought in the last 5 years as opposed to the last 50, they also matched the cover on the examination couch, which matched the chairs. I half expected the nurses to have uniforms that matched the curtains as well. Most exciting was the discovery of an en suite off the consultation room. Not just a pokey toilet, but an actual bathroom, complete with shower and bath. The excitement really was a bit too much…
This visit certainly opened my eyes to what "the other side" was like. Now, I’m not going to debate the relative ethics of private health care. No doubt one day when I qualify, I will do my fair share of private work and will enjoy the rather cushy surroundings and financial benefits. More-hotel-than-hospital is probably what they were going for, and I think I’d love being a patient there. But, it was all just a bit too surreal for me. Call me old-fashioned (or masochistic), hospitals aren’t hospitals unless they have certain features. The walls a faint generic shade of pea-green, squeaky lino floors and that reassuringly distinctive whiff of scented cleaning products not quite masking the delicate undertone of melaena… now that’s something I understand!
Like most people, I think I’ve been sleep-deprived pretty much since the start of my GCSEs when I was 15. I can’t blame it all on work; nights out and extra-curricular stuff probably have something to do with it!
But since starting uni, and especially clinical school, where life seems to happen at the expense of sleep, I’ve really learnt that sleep is somewhat optional.
I got called up at 7pm one evening and asked to go assist in an organ retrieval operation overnight. Not having put my name down for that day, I was not at all prepared and had stayed up later than was good for me the night before. It perhaps would have been sensible to get some sleep in the evening before the operation, but I was at my supervisor’s leaving party and didn’t want to go home. So I stayed up watching bad TV until midnight. And then went with the team to Oxford.
The retrieval went very smoothly and I was able to get very involved. After we got dropped back at Cambridge, I went straight to my (less exciting) lectures, finally going to bed late that evening. A couple of my friends have also done similar things, and most people who were undergrads at Cambridge have stayed up all night at a May Ball and then gone straight on to day-time parties. It wasn’t the ability to be awake overnight that surprised me, but the fact that I was able to function competently throughout it and then carry on the next day.
This must be trivial for most people, but it was a pretty big thing for me. I’d never pulled an all-nighter before this transplant and I’m pretty protective of my sleep normally! But ultimately, it must be mind over matter. In surgery, I had no choice but to be on the ball. I made a demand on my body and it responded. Undergrad was pretty mentally challenging, but I’m discovering the clinical school packs its punch in physical challenges. Bring it on! An education is not just in the facts you learn but also in what you learn about yourself, and that was a particularly satisfying lesson.
When All You Can Do Is Watch
The only thing that’s going through my mind is “oh my god, he’s 19.” He got a brain tumour, and he’s only 19. The surgeon’s talking about excision and radiotherapy, and I’m trying to compose my facial expression into something less shocked.
The whole family’s there -– mum, dad and son. Their reactions are heart-breakingly middle-class. Sat in the middle, as though being protected, the boy writes down key words “glioblastoma” and “high-grade” deliberately on a small pad of paper. No doubt there’s going to be a lot of wikipedia searching later, trying to make sense of the crashing into their lives. The dad’s pretty steely but he’s no fool; he places his arm around his son’s shoulders. The mum’s the only one shedding tears actually, and she’s restrained about it.
I don’t think the news came as a shock to them. And they all know what the answer’s going to be when the son asks, “I’m training to be a pilot; can I still fly?” No. That’s what he writes down in response. Meticulously, he writes that damning word down.
He acts as though it’s no big deal, like he’s just been told he can’t eat broccoli again. He doesn’t even seem to hear when the surgeon tells him he might still be allowed to drive. A career over before it starts. A life over before it starts. That’s what I saw today. And that’s what got to me. Most of neurology and neurosurgery is a futile fight. You prove to the patient that their taxes haven’t been wasted because you can tell them exactly why they’re getting those pesky symptoms. But most of what you do seems like blowing into the wind.
And as a student, you feel sometimes that you’re not even doing that. I imagine it as being by the side of a road, watching a terrible accident unfold. And not only can you not do anything about it, but the victim can see that you can do nothing about it. I have never wanted to be out of the room during a consultation, but today would definitely have been a good day for the ground to open and swallow me up. Every now and then, one of the family members would make eye contact with me. And I would return their nod or faint smile of acknowledgement, hating myself inside for being there. Because this is a moment of grief, and one deserves the right to experience grief in private. Did they mind me being there? Probably not. Are these situations unavoidable? Almost certainly. But it doesn’t help to be there when all you can you can do is watch.
The typical conversation about my future goes a little like this:
“Do you know what you want to do yet when you qualify?”
“Oh. Well, do you at least know whether you want to do medicine or surgery?”
Hurrumph! Why is there this divide in medical practice? And why should students know this distinction before they decide their area of interest, when this distinction is about the practice of medicine rather than its actual division –- into subject areas such as "cardiology", "gastro", etc.?
Thinking in particular about the rotation I’ve just done, neurology, the distinction seems much more a consequence of organisation rather than knowledge. To quote one of the neurology consultants, neurology is “diagnose and adios”. Much of the challenge of neurology comes in the diagnosis, the fine discrimination of possible options. In neurosurgery, the challenges seem to arise more in the management of their patients who are referred, often with diagnosis, from other areas. But they’re both dealing with problems of the nervous system. So, I kind of see medicine in general, and neurology in particular, as a coin, with one side as diagnosis and the other as management. Whereas physicians seem primarily concerned with the former, surgeons deal more with the latter.
But this sometimes seems like an arbitrary distinction. The vast majority of those in my year haven’t yet decided between surgery or medicine. And despite the pervading stereotypes of the specialties, most people would do well in either because your specialty shapes you as much as you shape it. When it comes down to it, it seems that most people will choose based more on lifestyle and work-style than on interest or competence. That really disappoints me because I didn’t go into medicine thinking “I want to be a surgeon” or “I want to be a physician” but because it’s fascinating.
Unfortunately, medicine isn’t there for my personal amusement; it’s there because the general population needs a health service. And because the practice of medicine sprang up distinct from surgery, which has its origins in a separate (more hirsute!) source, this divide has since remained both in practice and in training. Yet the body and its ills are not divided into management strategies; when will the time come for that to be recognised?
What a Doctor Does Best
The couple who walks into the neurology clinic are young and, ostensibly, in the prime of their adult life. The husband, the patient, is ex-army and used to being in perfect health. The consultant, who has already voiced his concerns to us before the patient came in, takes the history and leads the patient through a gauntlet of examinations. These elicit signs which are so classical that even I, the inexperienced student, know what the diagnosis will probably be. The consultant is gentle but firm and hints to the couple that the man’s symptoms indicate the more serious of two possible conditions.
The patient jokes wryly throughout the whole consultation, half using it as a defensive tool against the potentially life-shattering diagnosis. He openly admits that he’s in denial about his situation and expresses dissatisfaction at the blunt way in which his referring doctor told him "when you see something that looks like a blackbird, it probably is a blackbird." So the consultant explains his symptoms to him, helping the patient come to the conclusion himself. At the same time, the doctor tells the couple that he understands the serious ramifications of a certain diagnosis for the patient’s life and decides to withhold the label until the confirmatory scan has been done.
The patient’s wife has done research on the internet and has many questions, especially regarding a very experimental new treatment. This happens to be the consultant’s research interest, and he is able to explain his concerns in simple yet unpatronizing terms.
He guides the patient through the uncharted water of the probable diagnosis, discussing frankly best-case and worst-case scenarios, both comforting and yet imparting no false hope. When the consultation ends, the patient and his wife request that he continue to be their neurologist despite living 3 hours drive away.
As with such experiences, this one embodied all that medicine means to me -– the good, the bad, and the painful. Here was a doctor who was both competent and humane. Who was both scientific and clear in his explanations. Who understood not only the condition, but also the person. Seeing such an excellent clinician at work reminded me of the type of doctor I aspire to be. Medicine will always be defined and advanced by its people and it is always a privilege and pleasure to see one of their best, doing what he does best.