Overheard

In the waiting room:

"I've been having trouble with Bubba - he throws a tantrum and cries and spits when I try to breastfeed him!"
"Really? I've heard of babies that couldn't latch on well, but never one that actually hates breastfeeding..."
"Do you reckon it predicts whether he'll be a boob or butt man when he's grown up?"

More from Doc:
"All the Muslims want to take over the world and kill everyone....you're not Muslim are you?"

He also wants to invade Mexico and to tell his friend Malcolm Turnbull (our new Liberal [actually conservative] opposition leader, FYI non-Aussies) to scrap "socialised medicine" cos it creates too much paperwork.

We also had a patient today who was a former SAS officer (the CIA apparently wanted to recruit him once). His theory is that Muslim society is afflicted by inbreeding and the recessive genes make tards who are recruited as martyrs.

Teo and tangents

So I just finished watching the Enough Rope interview with Maverick Neurosurgeon Charlie Teo. Thought-provoking stuff. If you don't know his background, read on at Australian Story and Enough Rope.

The name Charlie Teo first crossed my consciousness this year, when I met one of his patients during my rural GP week. She'd had a tumour on her spinal cord and was handballed between various surgeons who told her it was impossible to remove. None of them mentioned Teo, the surgeon who was willing to operate on the inoperable. They were finally referred to him when the tumour was far advanced. They got to him just in time to save her life, but she was already a quadriplegic at that point. This lady and her husband were fair dinkum Aussie Battlers, and I say that without irony. Her husband had his own health problems - chronic severe back pain, multiple injuries from past car accidents, and was visiting the GP with pneumonia, requiring hospitalisation - but still managed to care for her full time. Despite their ordeals, they were philosophical, not at all self-pitying, and deeply committed to each other in an unsentimental, no-nonsense way.

To me, the Outcast Teo vs Medical Fraternity fracas highlights the contradictions in our noble profession. Questioning the validity of Teo's techniques is justifiable, but the visceral hatred he seems to evoke from the establishment goes far beyond the scientific. It comes from something baser, something like insecurity and jealousy and resentment.

See, on one hand there are the bright lights - doctors who inspire with their integrity, passion, intellectual precision, curiosity, compassion, humility, dedication and conscientiousness. I've seen these qualities in doctors at all levels, from humble residents, to GPs, to consultants (ie. Gods). I see the potential in many of my fellow students. The docs I had in Armidale were awesome. Being a small hospital, the structure was really flat - consultants actually deigned to talk to us lowly students and treated us as really really really junior colleagues. And they could teach, hallelujah!

On the other hand, I'm always wondering what patients would think if they really knew what doctors are like backstage. They are given so much trust, and abuse of that trust is so commonplace. Not so much the Dr Evil "mutilating genitals during surgery for kicks" kind of thing, but insidious, small betrayals. Using big words to take advantage of patients' ignorance. Never, ever saying "I don't know". Making referrals to specialists who've been nice to you, or not making referrals to specialists who've slighted you once. Putting on a façade of professional reassurance, only to talk crap about them behind their back. Using bias-based, not evidence-based medicine. Blaming patients for depression or addiction. Being careless with infection control. Doing tests or procedures that aren't strictly necessary to cover your own ass or make a bigger buck. Never admitting mistakes. Writing off some patients as basket cases, too hard, or not worth the bother. Aiming for "good enough not to be sued" rather than best care. I could go on and on. And the personalities, god, the personalities. Impenetrable vanity, arrogance, selfishness, apathy, laziness, bullying. I mean, I'm sure these things occur in all professions - petty rivalries and so forth. But people's LIVES aren't at stake in other professions, people's lives don't depend on whether Dr X's pride has been wounded or not.

I'm on Flynnie placement yet again, and in moments of particularly brain-numbing boredom I fantasise about the scathing portrait of my boss' foibles I'm going to write. A by-product of observing him for most of my waking hours. Let me try to capture some of his flavour. Our protagonist is a late-40's American ex-surgeon, a footballer who injured himself out of a career in college, dressed in all-American blue jeans and polo shirts. Adopts a folksy straight-shooting manner but bullshits his way around questions he can't answer ("What's idioventricular mean? It's something that's not working like it's supposed to. Like idiopathic, idiosyncrasy, one of those old Greek word things"). FoxNews devotee, son of a blue-collar worker, now multi-millionaire, casually racist ("Med school was so hard back in the day that two guys from my class killed themselves. Just couldn't hack the pace. They were both Arabs from Pakistan or something. Good thing too. Those people are all terrorists in the making"). He's threatened by and contemptuous of anyone who dares question his authority by showing any knowledge about their condition or using alternative therapies . Starts lots of sentences with "In medicine...", eg. "In medicine, this is called a puritic [sic] rash". Writes referral letters with really bad spelling and grammar. Asks "guess what I'm thinking!" kinds of questions to show off his knowledge or exert his power rather than actually discussing or teaching. Is impervious to student's eyes glazing over during his lengthy Pearls O' Homegrown Wisdom About Medicine - which he repeats. A lot.

A recent consultation went like this. A gentle, child-of-hippies type of woman comes in with diarrhoea and constipation.

Her: I had a look on the internet...and I know I shouldn't try to self-diagnose, but I was wondering if it could possibly be IBS?
Doc: Impossible. Can't believe anything on the internet. Inflammatory Bowel Disease is a very serious condition and it is very unlikely you have it...(etc etc etc etc)
Me: Um. Didn't she mean Irritable Bowel Syndrome?
Her: Yes, that's it. So I tried some natural medicines they recommended at the shop over there...

Doc instantly bristles, patronises her ("Cactus extract? What kind of cactus? There are many many kinds of cactus"), contradicts everything she says, and boots her out. After she leaves, he launches into lecture mode.

That there was a good lesson for you. What they don't teach you nowadays in medical school, which they did back in the days when I was training, is that you should never, ever let the patient take control. You'll see. When you've had 30 years of experience like me, you find out all patients want to use and abuse you. They'll come in with some scrap they've found off the Google and try to sell you some bullshit. Like that girl just then, she just flung piles and piles of bullshit all over the room. I picked it up right away, as soon as she came in - I've got my observations honed to perfection, it'll take you 30 years to get that kind of skill. Cactus extract! You saw how she tried to get her agenda on, but no way, I don't stand for that shit. You gotta learn that you're the doctor and you're the boss. She's a massage therapist - probably flunked out of high school - and she wants to tell YOU what to do! (etc etc etc etc)

Somewhere, an artsy-fartsy tie-died hippy-dippy anatomy-sucks ethics-roolz Newie lecturer is weeping. To be fair, I don't want to completely vilify him. He's got his charm and is great with babies. He works up his patients really thoroughly and goes the extra mile for them...at least the ones he likes. I can tolerate him...and occasionally learn a thing or two, though I now take whatever he says with a fistful of salt - he's quite capable of making up facts.

Praps I have this impossible ideal of Perfect Doctor - one that others, and no doubt I myself, will constantly fall short of. But the standard's got to be at least: "how would I like to be treated? what if it was my grandma?".

Ritual

First you have to get through the negotiations. You introduce yourself as a student and exchange pleasantries and nervous jokes. You put on your shiniest Bedside Manner, perky and polite. Almost invariably, they consent with self-deprecating good nature. Everyone's got to learn some time, right? I'm happy to help if I can. Yes, thank you so much - I really appreciate it. If you feel uncomfortable at any time, please let me know and I'll stop. Your group and tutor are standing around you, sometimes participating in this exchange, but often just silent spectators at the show.

It's a shifting of power. Once you have given them the semblance of control, you proceed to command them to perform all sorts of bizarre manoeuvres. Could you take off your shirt, please? And would you mind if I pulled your pants down a little further? Is it ok if I put my hand here in your groin? This is someone who could be your grandmother's age, or your father's. In everyday life, you would perhaps nod at each other on a sidewalk, or if you met, you would defer to them as your elder and better. Now, circumstances have contrived that you both meet here, in this place of delicately balanced vulnerabilities. You have to get past your own anxious voices. Am I doing it wrong? Do they all think I'm a tard? Am I making it up, or do I really feel this? Am I hurting them? This is embarassing.

But when you're in the zone, when you've passed all the awkwardness and anxiety and come to focus, finally the physical examination becomes an oasis. The laying on of hands, the strict order of the tests and the calm solemnity recall the rituals of the ancients. Feel a pulse - make sure it is not your own. Put your hand on a heart. Listen. The room is quiet, the clatter of the hospital fades into the background, and all you can hear is the heart beat and breathing. A steady rhythm, almost music. One-two, one-two. It is a moment of strange intimacy.

Month

Was that really less than a month ago that I was considering failure and running away and hiding? Btw I PASSED I PASSED I PASSED!!!! Victory is a little diminished by the suspicion that they wanted to pass us all because of the change in the curriculum. Whatever. The hell of academic semester is over.

Global Health Conference was full on. I can't remember the detailed stats about climate change and AIDS and the exact Millennium Development Goals, but I'm left with the troubling sense of the enormity of the challenges facing our generation, and the necessity of finding out how my own small life can fit in with the solutions. Nelson Mandela, that old fella, has a nice turn of phrase. It's all a bit overwhelming really...fuel crises, food crises, global warming, conflict, epidemics. It'd be easy to throw up your hands and succumb to fatalism, but as one of our speakers said, "we cannot afford the luxury of despair".

After that was Convention...a little ironic, after the heady inspirational rhetoric of global responsibility, to spend a week in drunken stupor and mindless hedonism. You know those Clubbing Montages in movies with the DUBDUBDUBDUBDUBDUB music and the flashy lights and jam-packed semi-naked bodies writhing rhythmically and making out and you go "pffft I'd rather be reading Jane"? Yeah. A week of that. Don't get me wrong, those nights were a blast in a "what inhibitions?!" kind of way (slightly afraid of and slightly looking forward to what photos surface on Facebook), but it's definitely a one-off for me.

There were other things. GP week was good. I didn't want to stab myself in the eye, the work of a rural GP is actually interesting and the area is one I can envision myself working in one day...although occasionally I do panic at the thought of the vast as-yet-unexplored wider world out there, countries I've never seen, whole classes of people I've never come in contact with. The peaceful country life appeals, but so too the call of adventure and worldliness that once made me want to be a languages, politics and law major aiming for DFAT or the UN or whatever the pipe dream of the moment was.

Anyway. My grandma is wise. Whether or not 2008 is actually celestially destined to be a good year, telling me that makes me determined to make it so.

Brainhack

So my brilliant idea of cramweek, aka insantorium, was simply this: a blog about learning. One thing that I was procrastinating about leading up to these Exams O' Doom was how to do learn more efficiently and I came across heaps of different approaches - photoreading, memory pegs, holistic learning, etc, but there was no one resource collating all this. There are blogs for students, but I'd like to focus on the principles of learning and not crap like "sleep before the exam" (pshaw! overrated!). Interesting to me at least, and I'd hope to make it practical.

Will it actually happen? Perhaps. I'll check it out more carefully, see what's already in the field. Been reading up how to monetise blogs as well, and if I do venture out and do this, I want to start if off properly...and that involves learning about SEO (Search Engine Optimisation) and blog techie stuff (CSS and server management crapola) and marketing and all that.

I've recently realised that if I ever do write a book, it'd probably be non-fiction as, alack, I cannot plot and my visual imagination is pretty crap. This is a potential topic. And I've decided that writing a book is one of my life's goals. It doesn't even have to be published. I just want to have the satisfaction. That's the liberating thing about non-fic - it's not a matter of talent. Beyond being able to string sentences together and structuring things, which I believe I can do, it's just perseverance and discipline and finding the right questions to answer.

Damn it's uncomfortable to air ambitions in public, even with, what, 2 readers? This is idle speculation at this stage.

66.66% done!

Today I...

• Had 3 hours sleep before my exam
• Sat one of my first OSCAs where I had to actually TALK to PEOPLE which I was scared about because a) I have not talked to humans for like a whole week and b) my sex counselling video was a total disaster and c) hello I'm an INTP! I hate people! hehe
  
• Was so nervous at some points I wanted to spew my Weetbix
  
• Counselled a fake patient about their herpes test results. I am in love with my tutor right now, because she STRONGLY HINTED that Breaking Bad News would be on the exam, so I actually looked up how to do it and had a framework for what to talk about and was practising "sorry, I'm afraid the HIV test is positive" last night in fact (aloud to myself). It went better than I thought it would. Was grinning all the way out, probably just the adrenaline. But it was like....maybe I'm not actually not as inept as I'd thought. I can do this stuff. I can do people. I listened reflectively! I empathised! And it didn't feel too fake!
  
• Completely blanked on how tiredness would relate to indigestion. Well actually the question was, "how would this change your thinking?" but I was too stuck on reflux to expand to cancer and systemic diseases and haemorrhage. STUPID!
• Had to scurry from the main exam room to the counselling rooms twice. Felt so sorry for the year manager because it's a huge logistics nightmare..they had to shuffle students up and down the corridoor like ten times, and sometimes people were too dumb to realise it was their turn, or went over time. There were walkie talkies involved and they had to co-ordinate timing and stuff.
  
• Took lollies from a stranger
• Took free tea
  
• Got into a car with an acquaintance on a whim, cos he asked if we wanted to go to lunch. The food was semi ok though we did have "what meat is this?" *taste* "I still can't tell" issues, but it was fun talking to people I don't know well.
• Told a guy he reminded me of my seedy uncle. hahahaaha he so does. He's our The Todd...a wannabe beefcake, real Alpha Macho "I like beer and cars and guys who don't are faggots" type. So closeted. Hilarious though. He smokes! We just did lung cancer, emphysema, ERECTILE DYSFUNCTION, diabetes and osteoporosis, and he smokes!
  
• Had to amuse myself on blank OSCA stations. I did half a sudoku and some word thing, but that somehow made me more stressed when I couldn't think of a three-letter colour ending in e, so gave up. Then I made a paper plane which I really wanted to fly, but that would probably be against the rules or something. So lots of the time I sat with my eyes closed and played air piano. That was calming. Also this breathing technique I learned from Mind Performance Hacks...you take deep tummy breaths in for 3 counts, hold for 3, out for 3. Stops the hyperventilation.
  
• Surprised myself at being slightly disappointed that this guy I know has a girlfriend. I never thought of him as potential! Not that he's that attractive, he's just the nerdy semi-weird but nice type I'll probably end up with.
  
• Wondered if the faculty made the questions less demanding this year because they don't want to fail anyone since they're changing the curriculum next year. They're dropping the Regional Rotation would you believe?! This is "We Need YOU to be a rural GP!" Newie we're talking about! And it's entirely for logistics not educational rationale. What a shame. The clinical stuff is, I hope, what will make us think of ourselves as Doctors to Be for the first time, and prepare us more for the real world than this "sit in a room for a week and cram" bit. Shame on you, Newie! This is partly a result of government policy I think. Making new places in med school sells well politically - "look, new doctors on the production line = totally the solution to the shortage!" - but there's the small matter of the hospital system accommodating for the extra training that we wide-eyed wet-behind-the-ears types need. And seriously? GP community placements won't cut it.
  
• Practically danced out of the exam. Such a weight off my chest. The written parts were ok, and regardless, having the two OSCAs out of the way means this hell is almost over.
  
• Asked someone how they coped with failing last year. I'm surprised at who fails. Some of them are obvious slacker "I accidentally got into medicine" types, but then there are also the really studious and serious Malaysians, as well as the outgoing and at least verbally impressive types who teach anatomy and stuff.
  

Ahhh. Such a turnaround from last week. Some of the conclusions I drew then are still true, but I'm on less of an emotional hair trigger now. There is hope. There is life beyond Wednesday. This career is not a trap.

Holyfuckingshit, if I pass these exams, I am HALF A DOCTOR. Or at least half an intern. Dr T-Dizzle. Snort.

Rosebush

A portrait of a nervous breakdown. In the past week, I....

• Attempted to cram: dermatology, ophthalmology, diabetes, endocrinology, hepatology, nephrology, orthopaedics, immunology, infectious diseases, cardiology, neurology, respirology, rheumatology
  
• Burst into tears multiple times, including weeping at the piano
  
• Seriously contemplated skipping the joint and running away to do volunteer English teaching in South America, to Find Myself and fucking rebel for once.....to the point of wondering how I can get a debit card and what kind of camping gear I need
• Stayed up til 6-7am
• Studied in bed, in the bathroom, in the kitchen, on the dining table
  
• Did not do any exercise beyond going downstairs for food
  
• Read about 1000000 pages of notes and realised just how many lectures I napped in...the handwriting would start off impeccable and then deteriorate to scribbles by the end, heh
• Relived some of my and Ru's intra-lecture exchanges via our margin graffiti
  
• Thought about what I wish I'd told my first-year self: 1) from the beginning approach med as if you were gearing up for the physician's exam, to be a Real Doctor...rather than studenty "I just wanna know enough to pass" or "this isn't on the curriculum" attitude, 2) COLOURFUL PENS and highlighters make a world of difference to how much you feel like studying....typed notes in table format are boring, 3) reading up BEFORE the week starts makes you feel smart and feeling smart makes you study more and studying more actually makes you smarter.
  
• Drank a LOT of Irish Breakfast, English Afternoon and Earl Grey tea
• Obviously peed a lot
• Wondered if I should take the USMLE boards just to solidify my knowledge in the basic sciences
  
• Learned that apparently bee venom is good for fatigue in MS
  
• Wore the same clothes for about 4 days straight
• Undressed to go to shower only to realise that my mum had set the house alarm and had to run downstairs, redressing on the way, to turn it off
  
• Practicised that Granados Oriental piece a bazillion times. Still got to do the middle bit, but am getting pretty good at the first bit except for that fiddly trill
• Did not leave the house for an entire week
• Drank about 12 boxes of lactose free chocolate milk (not that I'm intolerant, it was just free at the GP convention)
• Hit my head against desk
• Snapped at my mother
  
• Talked to myself, a lot
• Ate a lot of mandarins and bagels
  
• Wondered if Jerry blogging was a three-year cry for help
  
• Invented retarded mnemonics like "quatre femmes sit on your lap doing high kicks" (quadriceps, femoral nerve, anterior thigh, extension) (ok, I'm actually proud of that one. the stupid ones are the ones that I make up and then promptly forget)
  
• Realised that I hate medicine and the only things stopping me from ditching it are 1) debt - this bonded thing is a MORTGAGE ON MY SOUL, 2) all these textbooks going to waste, 3) my grandma would be really sad
• Realised I actually enjoy some of medicine and want to be good at it and in my dream "running away to S. America" scenario I'd bring my OHCM
• Discovered that I like pathology (though not the microscope aspects, the mechanisms) and microbiology (cos bugs have identities) and immunology (very logical, fits warfare metaphors well). I hate rote rote rote learning anatomy and drug names
  
• Went outside at 5am, thought about jumping in the pool with my pyjamas on
  
• Considered my extra-academic marketable skills and came up with...diddly squat. Well I can type, write ok, speak French halfarsedly.
  
• Prayed to, and railed at, god...who, by the way, hates humanity, going by some of the horrendous diseases I've seen
• Did nothing but eat, drink, poo, pee and study for days on end
• Told myself I'm a fucking idiot because I'm 22 and all I've done is study and I'm going to fail at that which means I fail at life
• Realised that failure could be liberating and motivating and a Life Experience because I've had it all my way til now...a test of character
  
• Napped on the floor of my study
  
• Decided I need a life: closer friends, diverse interests, a job, LOVE SWEET LOVIN'
• But decided I'm not really ready for the latter til I'm totally happy with who I am, which is not yet
  
• Realised that I have never strayed from the path of least resistance in my life -- never made an autonomous choice, never acted against the destiny set out by my milieu (school, uni, make money, consume)
• Was cheered by reading silly forum posts on the internet
  
• Helped a friend do her job application letter
• Wondered, in the darkest depths of 5am self-pity, who I could call for Listen&Support at such an insane hour...but as always, kept myself to myself
  
• Got really excited about a potential new blogging project and procrastinated for a bit drafting up ideas and posts and thought about how I could even maybe turn it into a book
  
• Woke up the next day and reconsidered it and thought it's probably stupid
  
• Wrote half a post about how my family is totally fucked - >80% divorce rate, some multiple. Also realised I have no blood aunts! Well only one, but she's estranged.
  
• Tried to meditate
  
• Realised that this is all bloody self-indulgent and melodramatic because I have had it so damn easy: parents and grandparents who love me, money, education, health, opportunity...a giant big fat cushion of privilege...not that it was much comfort at the time
• Realised that one day I'd look back and laugh in disdain at myself for thinking that THIS was stress
• Was told by my grandma that according to astrology this year is meant to be a good one for me....hahahahaahahahaha right.
  

Phew. Catharsis.