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Old School vs New Tricks

Luciali72x722Lucia Li -- "Nothing that is worth knowing can be taught."

One of my first-year supervisors told me that I’d be lucky if I remembered even 20% of the stuff I learnt in medical school. I think he was intending to cheer me up, but I remember thinking that if I was going to forget 80% of what I learnt, I really hoped it would be that stuff about ribosome units and mitochondria, and not the stuff about hearts and brains.

The first 3 years of our course are filled with lectures and lab-work, and the sum total of patient contact in those years is about 12 hours. Some of this basic science is a bit more obviously relevant than other parts… anatomy and physiology and pathology. Others still seem a bit obscure. Whilst I lost sleep as an undergrad trying to remember Gibbs free energy equations, my friends at other medical schools lost sleep over cases on heart attacks.

Inevitably, people ask what’s the point? The current drive is towards making medical courses more directed and cuddly, with the 4 new UK medical schools all providing integrated courses. Buzzwords such as "Problem-Based Learning", "Student Selected Components", etc., pervade. When the GMC (the UK professional regulatory body for doctors) came to inspect the Cambridge course, they asked us a lot about what we thought about the heavily scientific nature of the course and its relative paucity of early clinical experience. Apparently, we surprised them with our enthusiasm, prompting them to ask, "Did they pick you guys [to meet us] because you’re so positive?" No, actually.

Why wouldn’t we be supporters of our course? First of all, I’d imagine most of us knew what we were getting ourselves into when we applied, and most of us have enjoyed Cambridge because of, not in spite of, its scientific nature.

Second, I really believe that all this emphasis on early clinical exposure is a bit overrated, whilst science is underrated. You don’t make medical advances without research and scientific principles, and you can develop a bedside manner and good examination skills just as easily at the age of 21 as at the age of 18.

Diversity of experience should be celebrated in medicine, and part of that is the differing medical course styles. Yes, until a year ago, I knew more about guinea-pig hearts and Drosophila genetics than about how to examine a patient. But, as long as you’re competent at the bedside, I doubt anyone really cares where you graduated from 10 years down the line. Besides, all those random facts come in pretty useful in pub quizzes…

September 26, 2008 by Lucia Li | Comments (4)

Medical Specialties From a Student's Experience

Luciali72x721Lucia Li -- "Medicine is learnt at the bedside."

The grass, in the case of medical education, probably is greener on the other side. As students, we don’t have to do evil paperwork. But then we don’t have the inconvenience of being paid, either… Already through my attachments, I have been surprised (both pleasantly and unpleasantly) by the difference between my expectations of different specialties and reality. At the same time, I know that specialties are very different for a doctor than they are for students.

What makes a good attachment for students? For me, it’s nothing too miserable, staffed by good people who like to teach, well-organized, coherent patients… oh, and time off to pursue student-like activities.

Here are my winners and losers of specialties to be in as a student.

The losers:

Oncology – My housemate, currently doing this attachment, informs me that she had never really experienced true vicarious depression until this time. We’re taught to be empathetic in our clinical communication skill courses and to say such helpful sentences as "I understand" and "I can see that must have been difficult for you." But, when you can do nothing as a student but say such platitudes, your own ineffectiveness and inability to help is blindingly apparent.

Care of the Elderly – It has to be said, this specialty is generally staffed by the most jolly and eccentric of doctors. The bow-tie wearing and ancient Greek-quoting kind. However, whilst there were some real gems, it was very frustrating to see what is essentially social care carried out by doctors because there was no one and nothing else.

The winners:

Orthopedics – In our hospital, all the orthopedic surgeons are happy. Seriously happy. Not just your average, I’m-contented happy. But a proper, I-love-getting-up-in-the-mornings happy. And their specialty involves cool toys and gruesome operations that students can really get involved in. However, what really sealed it for me was probably the CD they played when we were in theatre; anyone who plays the best of the 90s whilst screwing pins into knees has my respect.

Psychiatry – I have no aspirations whatsoever to be a psychiatrist, but this really was a fun specialty. Where else do you have patients that tell you they don’t think the world is real, or have the police involved in coaxing people out of peculiar hiding places? Plus, psychiatrists have the comfiest chairs in their offices.

I’m sure I’ll change this little ranking system as I see more specialties. But for now, I’m heading back to the land of happy people.

September 21, 2008 by Lucia Li | Comments (4)

Are Doctors Supposed To Be Perfect?

Luciali72x721Lucia Li -- "To be trusted is a greater compliment than being loved."

Janus, the Roman god of doors, is represented with two faces. Reminds me of medical students. There’s the face we present in hospitals -– decent, wise, moral, caring, confident. And washed. Then there’s the one we have when we get home –- tired or angry or uncertain or petty. Essentially flawed.

There has been a recent debate in the UK regarding the withdrawal of an offer made to a prospective medical student by Imperial College London, when the admissions offices found that he had a previous criminal record. The student had taken part in a robbery at the age of 16, for which he’d completed the community service required and had done substantial amounts of volunteering work since. He was also a straight A-grade student. Opinion was divided about the decision. Some argued that ICL was wrong because the decision sent out the wrong message. Here was a person who had not only atoned for his punishment but had also turned his life around from his criminal past. The withdrawal, his supporters argued, showed that society was unforgiving of juvenile delinquents and would not allow people to change their ways, forever tarring them with the mistakes of their youth. On the other hand, there were those who thought that ICL had acted correctly because those within the medical profession should deserve the trust which our patients give to us; we should be above reproach.

But, of course, we’re not. Although most of the time, most of us are the consummate professionals and decent, moral practitioners that society wants us to be, we are still fallible because we are human.

We drink. We smoke. We lie. We are cynical. We eat chips. Everyone has moments of weakness. But, how much does this matter when it occurs in our personal life? Should the things we do as people outside the medical arena impact our reputations within it? Where does personal life end and professional life begin?

As long as one can always assume the role of the competent, caring and confident doctor at work, does it matter what one is like at play? Is it right for a speeding offense to be listed on the internet, accessible to the general public? How much does one’s behavior outside the medical world say about one’s competence as a clinician?

This leads to another issue. Let’s say a medic drinks more than they should on their days off, maybe even been brought into A&E with alcohol-inflicted injuries, but never turns up on duty drunk and disorderly. Can trust still be maintained despite this apparent separation? Or is there too much of a risk of the consequences of this behavior bleeding into the professional sphere?

The third issue relates to the perceived "severity" of the off-duty behavior. You might continue to trust your colleague if you knew they drank a bit too much at Christmas. Maybe even if they were compulsive gamblers or drove like a maniac. But what about behaviors which hint at a truly nasty side? What if they made racist remarks? Or participated in fraud?

The majority of doctors and medical students are, fortunately, free from serious bad behaviors. But even the purest of us will have aspects of our character which we would wish to remain hidden from our patients and colleagues. In fact, this selective presentation of ourselves to the world is usually intertwined with our notions of personal privacy. But should doctors lose this behavioral anonymity, open up to scrutiny and be judged whiter than white before earning the right to be doctors?

September 14, 2008 by Lucia Li | Comments (69)

Psychiatry Just Isn't For Me

Luciali72x722Lucia Li -- Neurotics build castles in the sky. Psychotics live in them. Psychiatrists collect the rent.

I’ve just finished my first specialist attachment, 6 weeks in psychiatry. I must say, I am so relieved and happy that it’s over. Not that is wasn’t useful, but it just didn’t float my boat.

When I was much younger (and thus, much less wise), I thought psychiatry would be a really cool thing to do. But I suspect I just wanted to peer over horn-rimmed glasses and say things like “so, tell me about your dreams”. Unsurprisingly, psychiatry isn’t quite like that. It’s a true Cinderella specialty -– underfunded, understaffed and seriously underappreciated. And this is one of the major reasons why I couldn’t do it; most of us going into medicine have at least a smidgen of altruism, but with Autonomy being one of the 4 ethical principles, it just feels unsettling and unfulfilling treating people who often do not actively seek or even want your help.

Another major reason is the science behind psychiatry or, rather, the lack of it. When we did experimental psychology as part of our basic neuro teaching in pre-clinical studies, it was absolutely fascinating to learn about the animal models, functional imaging studies etc. of all the different disorders, but clinical psychiatry just does quite cut the mesh for me. There’s very little evidence regarding many of the interventions, for example, psychotherapy. Not to mention the fact that disorders are not characterized by their aetiology, but their presentation. On the one hand, this really makes psychiatry a clinical speciality –- the clinician’s experience, handling and interaction with the patient is absolutely key. And this also makes this speciality a brave one; treating people with drugs and treatments for which the mechanism of action is ill understood. But on the other hand, the subjective nature of this doesn’t sit well with how I would like to practice as a doctor.

Ultimately, I think what really sealed it for me was the lifestyle. I do not appreciate being bored and quite enjoy being time-pressured, having never really experienced anything else. It may have been the attachments I did, but the pace of life in psychiatry is interminably slow in comparison to the cut and thrust of hospital medicine or surgery. This is also one of the reasons why I don’t think I could do general practice. It’s telling that the 2 weeks of psychiatry I vaguely enjoyed were the ones I spent with the Crisis team! Choosing a speciality is about a lifestyle as well as the medicine, and psychiatry disappointed me in both regards.

Psychiatry is a marginalized speciality; many doctors view it as "not real medicine", psychiatrists themselves get lumbered with unflattering stereotypes, and you practice it knowing that you very rarely cure anyone. For this reason, I have huge amounts of respect for the people who go into it, either as nurses or doctors. My experiences are obviously by no means unique (otherwise we’d have too many psychiatrists!) but I don’t mean to denigrate this fine speciality. It’s just not the speciality for me. So, roll on the next attachment…

September 4, 2008 by Lucia Li | Comments (11)

You Are What You Watch?

Luciali72x721Lucia Li -- “Idiot’s are fun; every village should have one.” – House

Medics are split into 2 camps: those who hate medical dramas and those who love them. I’m firmly in the latter. "Grey’s Anatomy", "House", "ER", "Scrubs", "Casualty" (a UK version of ER) … sad though it is, almost any TV series set in a hospital will have me tuning in. You’d think I get enough medicine in my day job, but apparently not. In fact, I never used to enjoy these programs until I became a medical student. Some of my medical friends joke that it was programs such as these that first got them interested in medicine whilst others claim that watching them reminds them of the light at the end of the dark tunnel that medical training can sometimes be. If you are a medical TV addict, I suspect you’ll have other reasons of your own, which I’d be really interested to hear about. Meanwhile, here’s what they mean to me:

Scrubs -- This show does, indeed, speak the truth. It paints such hilarious caricatures of the worst of hospital life that you can’t help but laugh, rather than cry.

House -- The one we should all aspire to be. In terms of knowledge if not in grumpiness. Plus, it was the first program that really made the medicine, the chase of diagnosis, interesting, rather than the lives of those who practice it.

Grey’s Anatomy -- Very pretty. Full of beautiful people, sexy medicine, sweeping storylines … what’s not to love? And it’s really one of the only programs that really ram home the difficulties in the lifestyle of surgery -– the hours, the sacrifices -– whilst still making it seem worthwhile … thank God!

ER -- Who doesn’t love ER? Written by ex-medic Crichton, this series has actually taught me medicine or at least reinforced it. That episode with the blackout in Season 4, where Carter stops someone’s tachycardia by plunging his face in ice-cold water… the diving reflex has never been illustrated so well!

Nevertheless, no matter how realistically the dramas claim to portray the life of doctors, this is pure escapism. The image of medicine given is essentially shiny. The struggles and worries that face these TV doctors may be realistic, but the way the characters deal with them is only possible in the fantasy land of TV medicine. For example, in the modern NHS, what house officer gets assigned only 1 case for the entire day, giving them time to agonize over the ethics of it? Or the way the characters interact, whilst honest, borders on unprofessional in many cases. The characters themselves are caricatures of medical stereotypes; most medics are made of varying proportions of those traits! But, frankly, when you’ve got the likes of McDreamy and Carter on-screen, who can begrudge a little suspension of reality?

August 27, 2008 by Lucia Li | Comments (17)

We Heart Nurses

Luciali72x721Lucia Li -- “Interns think of God, residents pray to God, doctors talk to God, nurses ARE God.”

After being on numerous attachments, personal experience has taught me that nurses really can make or break the experience you have. Not that I’m surprised by this: nurses are the ones who know the patients best, who know where everything is, who will be implementing the care you instigate and, most importantly, who offer you biscuits. It’s surprisingly tricky, however, navigating the minefield that is nurse-doctor etiquette, but something I’d recommend all medical students start working on whilst they’ve still got the cloak of ignorance to hide behind!

From experience, talking with nurses and watching the best (and worst) examples of doctor-nurse communication, I have devised my top 5 tips for getting on with nurses:

1. Introduce yourself to them at the start of attachment. A name is so much nicer than an ID badge, or even one of those sexy little tags saying "medical student." I know, common sense, but it’s surprising how it’s lacking in your average medical student…

2. Admit ignorance. Most nurses are quite mumsy in nature –- they like nothing better than to look after a lost little medical student. Don’t look too lost or for too long, though; nurses do actually have better things to do. Like look after doctors.

3. Run everything past them. Even if your consultant has said it’s ok to go speak to a patient, s/he may not have seen them for a few days and the patient may have deteriorated. Or they might be about to do something to the patient. Either way, they rule the ward so it’s probably best.

4. Understand how hard it can be for them. There was a doctor on my second attachment who, on starting his early ward round, was told by the nurses that they’d had a really busy night and weren’t quite ready. I’ve seen other doctors snap at the nurses for that, saying that if they could be ready, so should the nurses. But this doctor quite calmly said that he’d do another ward first and then come back. "Manners maketh the man." How true.

5. Pitch in. As medical students, our role in patient care is to learn, and this should be our focus. But sometimes, we need to pitch in. Even if wiping soiled bottoms or helping a patient go to the toilet isn’t quite what we signed up for, it’s a simple thing to do that helps a fellow healthcare worker who will appreciate it.

Other people with whom it’s important to get on in your firm:

1. The junior doctor, aka general dogsbody. This poor person will be rather harassed, so they’ll love you if you make an effort to help them, e.g. find blood forms. They’ll especially love you if you bolster their fragile egos by asking for advice and/or teaching (when they’re not busy); depending on how long it's been since they experienced the dizzying success of passing Finals, they will have had their self-confidence crushed into the ground several times.

2. The ward clerk. This person doesn’t participate directly in patient care, but s/he keeps the log of all the patients. This is also the first person you’ll see every day coming into the ward, and who wouldn’t rather be met with a smile than a glare?

3. The other medical students. No kidding.

As much as the patients, I personally feel that it really is the people on the firm to which you’re attached that make the difference to your enjoyment and your learning. Whilst it’s absolutely natural to try to get on with your consultant, your relationships with these other members of the team are just as crucial… and they’re the ones who will be there with a cup of tea when the going gets tough.

August 14, 2008 by Lucia Li | Comments (14)

Women in Surgery

Luciali72x721Lucia Li -- Q: What’s the definition of a randomised double-blind study?

A: 2 orthopaedic surgeons looking at an ECG.

God bless orthopaedic surgeons… This particular joke got me thinking about all the stereotypes in medicine -– not least of which is that of the male surgeon. I know it’s hardly fashionable these days to admit that women still don’t have the same opportunities in work as a man, but one only needs to look around the operating theatre to realise that 9 times out of 10, the females in there are either scrub nurses, the anaesthetist or the patient. Why is surgery still such a male-dominated speciality? Here’s my tuppence.

1) Our generation simply hasn’t gotten there yet. It’s only been a relatively recent phenomenon that female medical students outnumber male medical students, so maybe, given another decade, the slow trend of increasing numbers of women consultants will also begin to be seen in surgery.

2) Women aren’t suited to surgery. A Cambridge surgeon caused quite a furor in 1998 when, in a Lancet article, he suggested that women simply weren’t suited to surgery; one of the reasons he gave was that men cope better with sleep deprivation than women. As a woman, I obviously find this idea unpalatable, but it did get me thinking about it more seriously. Traditionally, medicine is a brutal career. Before the laws controlling the number of working hours were introduced, being a junior doctor often equated to sacrificing a home life for a good few years. This was no more true than for surgery, which even now demands long hours of its trainees and consultants. Given a traditional nuclear family set-up, which I think is still widely pervasive, when it came to childcare, it would be the female partner who took time off work. It is thus perhaps unsurprising that men have dominated surgery for some time. However, as flexible training and job-share is increasingly a real workable option, it has allowed women to see surgery as a real option. Rather than women being unsuited for surgery, it was perhaps the lifestyle which was unsuitable for them.

3) Specialties attract their own kind. For every female who felt uncomfortable in the surgical environment, there is probably a male who felt uncomfortable in the OB & GYN environment. Pity the male whose patient would rather have a female doctor as much as the female whose patient was expecting a male surgeon. Surgeons have the stereotype of being extremely self-assured and ruthless. Whether this has anything to do with the way that surgeons must be to be successful is largely irrelevant. The important consequence is that a very macho and competitive environment is fostered. Some people love this sort of environment, love cut and thrust, and it is the world they wish to enter as much as the professional challenge of surgery. Equally, some people hate the vibe this creates and don’t want to be that ruthless. The flip-side is that when it comes to selection of candidates, those who display similar characteristics as the surgeons making the selection will more likely be chosen. This is equally applicable to males as to females, it’s just that when this happens to a female, she and others are more likely to attribute this to her gender rather than her personality.

In one of my regional placements, I met a surgeon who said that “women are killing surgery”; what he meant was that as the majority of medical graduates are now women, most of them will shun surgery for its stereotypes. This will reduce the number of good candidates going into surgery, lowering its standards. Surgery needs to attract women for continued excellence in practice. I am uncertain about the benefits, or even the need, for positive discrimination, but educational initiatives which promote surgery as a realistic career option for women are vital. Both the patients and the profession can but benefit from a world where females are encouraged to explore surgery, building up a "surgical CV" to enter and compete on an equal footing with male candidates.

Editor's Note: This is Lucia Li's inaugural post on The Differential. To learn a bit more about her background, read her short biography.

August 1, 2008 by Lucia Li | Comments (71)