First Day

So I can happily say that I survived my first day of being a GP registrar. I stayed back late too, and I wasn’t actually grumpy about that, unlike being in a hospital rotation. Which I thought was quite unusual actually.

After an awesome 2 days at an island resort attending official orientation with the GP training organization, I was a little apprehensive about starting today. Thoughts filled me with dread about what to do with the extremely difficult patient. What if the patient doesn’t like me? What if I bother my supervisor too much? What if I forgot to do a critical investigation?

So I went in this morning to the practice, all tensed up and nervous. I got the software training, and had a tour of the place. Can’t believe there is a CT scanner downstairs at the practice!

And when I got around to seeing my first patient, it wasn’t actually so bad. Having experienced ED at the hospital, the patients there had been very unwell, and it always felt like I was waiting for a consultant, and constantly waiting for someone to make a decision because I wasn’t experienced to make that call. And if patient’s had built up, the whole department got stressed, with team leaders pretty much yelling if you were too slow.

I didn’t experience any of that today fortunately. And the patients I saw were pretty lovely to be honest (which I guess I wasn’t really expecting working in a low socioeconomic status suburb).

My very first patient – menorrhagia after going off the implanon. This has been for 2 years since removal of the implanon. Should I put her on the pill, or should I refer her? When is the normal time frame after implanon removal when patient should have regular period again? All this I didn’t know, so asking the supervisor, he advised that I should refer her. And to do a speculum, since last one was done about 1 year ago when she had her pap smear.

And at the end of the day, I have a list of stuff I need to look up in more detail to fill my gaps in knowledge. Things like implanon contraception, hypertension management and investigations, and tinnitus.

My supervisor later told me how specialists would be well gunned for complex and really heavy illnesses, but for common things, would have no clue how to approach. He shared the example of a paeds consultant not knowing how to manage a child with VSD who got a simple finger laceration. The patient got stitched, and given gentamicin (which is overkill). But hey, in general practice, a good GP knows how to manage simple problems, and if its out of their scope or requires specialist intervention, a referral is appropriate.

In a way, that’s why I chose general practice. A specialist is excellent in their field of specialty, but for other things – they have no idea how to treat. A GP knows how to manage basic conditions for almost everything, but not to levels of expertise like a specialist. But for things like a rash or bump/lump, I can imagine the cardiologist telling a patient to “go and see the GP”.

Having worked in the hospital for the past 3 years, I can say that the first day of any of my rotations have not been as satisfying and bringing content as general practice.

The Last Day of Hospital

Today was officially the last day of hospital. I was doing the dreaded postnatal checks (which I have done usually on Saturday, and those were busy as ever), so imagine my surprise when I went in today to find only 9 postnatal discharges (I have usually had to do 14- 18, with many ward call jobs as well in between).

By 12 noon, I had managed to see all my patients. Best day ever I must say. It has never happened before, and I am so glad that it happened on my last day of hospital.

Even the PAOU (pregnancy assessment and observation unit) was “quiet”, so they didn’t really need the help I offered them. So, I ended up spending 5 hours doing something productive like reading up stuff on medicare (prior to my orientation tomorrow), and some stuff on hypertension.

Also, today was a really nice day. Last few days have been muggy days with 33 degree temperatures. Today was a nice 27 degrees. Very pleasant.

Looking back at my 3 years in hospital, I can say that I’ve come a fair way. But being in training as of tomorrow, I have even more to go. Hospital time was stressful at times, but I can certainly say that I have learned a lot from it, and I am grateful to my patients, to my colleagues and the to the registrars and consultants who gave me great support and educational opportunities.

Before I left the hospital, I posted some internal mail to “Human Resources” with my ID badge, parking card and a letter written on a progress note.

“Dear Human Resources,

Please find enclosed my ID badge and car parking card.

I have had a wonderful time working here at the hospital.

Kind regards

The Placebo Effect

 

I dropped it off at the internal mails box, to never see my name badge ever again.

Leaving the hospital, I crossed the street, before deciding that I needed to take a photo of the hospital entrance, and so went back. Just like my last regional hospital, I don’t know when I’ll be passing the entrance again.

I race off to catch my bus, thinking that this is the last bus ride back home from the hospital. A nice finish to the day, and a nice finish to the last day in hospital. I need to pack my stuff up for tomorrow for… The start of orientation as a general practice registrar

Last Week

Having spent close to 3 years in the hospital system, I have just one more week before I permanently leave.

General practice here I come!

But honestly, these past 3 years have been challenging, rewarding, and I must say I have come a fair way from being a medical student.

In 1 weeks time, I am no longer a resident anymore. I’ll be thrust into the world of general practice, where almost anything is fair game. I’ll be a registrar, and that means being thrown in the deep end.

One more week of obstetrics and gynaecology. I don’t think I’ll miss the postnatal checks, because they were very mundane. But I suppose I will miss scrubbing in for cases. Next week will be the last time probably I scrub in to assist an operation again.

Much work lies ahead… Hopefully I’ll be ready for it!

Postnatal Checks

Having been on obstetrics and gynaecology, I have had to do a fair few postnatal discharges as a resident.

These postnatal discharges are quite repetitive I must say, in that it’s always the same questions. You find out how they delivered their baby, what blood group they are, whether they are rubella immune or not, what complications arose in labour etc.

With any woman that has had a 3rd or 4th degree tear, they have to had opened their bowels before they are allowed home. In addition, they must be getting regular laxatives (usually lactulose) while as an inpatient.

Around the time of Christmas, I see a woman who had a 3rd degree tear. She hasn’t passed bowel motions for the last 5 days. Reading through her notes, she’s been seen by previous residents, even had a general surgery consult in regards to exclude any anal dysfunction. I panic at the prospect that I have to see her.

I eventually decide that I need to see her everyday, after looking at the anus, and noting normal anal tone. She tells me that she’s starting to get abdominal pains, and I think I can feel the poo in her tummy on palpation. Poor thing.

For the next 3 days, I see her every day, always asking if she has pooed yet, and if she has passed wind yet. Still no. It’s about 2 days out from Christmas. The patient informs me “I really do hope that I pass a bowel motion soon. My wedding anniversary is on Christmas.”

I make light of the situation (it’s too good to pass) “Oh goodness. I sincerely hope that you won’t be in hospital waiting for a poo on Christmas and on your wedding anniversary!”.

Pumping her full of laxatives, the patient questions my medical management. “Is there anything else you can do aside from just giving laxatives? I mean I’m really concerned something bad is happening”. I reassure her that the abdominal x-ray series has excluded a bowel obstruction, and that we are giving optimal medical management.

“There is no other alternative aside from either manual disimpaction or inserting a tube up your anus to flush the poo out. But with your 3rd degree tear, those aren’t really good ideas”. The patient almost faints after I explain manual disimpaction, wriggling my index finger. “How will the index finger get the poo high up out!!!???”

I think I was enjoying myself too much teasing this patient. Not in a mean way, but in a light hearted way so as to make the situation less serious.

After seeing her on the 3rd day, news gets out that she has some incontinence. Only a few mls according to the patient however. An hour later, and she has opened her bowels with a massive amount of faeces. I try to see the patient to congratulate her, but she seemed pre-occupied in the toilet. Unfortunately, I wasn’t able to see the patient as I had to rush off to the clinic. But I’m proud of the laxatives I gave this patient.

I feel happy for the patient. At least she doesn’t need to spend Christmas and her wedding anniversary waiting for a poo.

Year Long Sacrifice

Reflecting back on the events of this year, I’m amazed at how fast time has gone.

First comes the moving back to the big city from a regional centre, then comes the job applications and interviews for general practice positions, and now finally, I have finished my paediatrics diploma in child health exam! Well, to be more precise I sat the exam on Friday, and only had time to write about it now. I’m such a bad blogger :p

No more needing to rush home to study paediatrics. No more weekends spent listening to online lectures. No more stress!

I was lucky to have been able to take an entire week out to study, which was really helpful. My work colleague jokingly told me off on the bus after the exam, saying how busy it got in obstetrics and gynaecology without me. She ended up having to do my postnatal checks in addition to hers. But, I had to do that for a week before, when one of the previous residents resigned as well. So in my defence, I can at least say I’ve done the work before.

But after all this, I feel like I need to start preparing for study for general practice… A life in medicine entails exams till you’re at least 30 years old.

Now, at least I can come home without need to worry about intense study at least. I can study at a somewhat more relaxed pace for general practice.

 

Signs of Impending Death

The title of this post may sound too medically based, since it seems to focus more on just the signs of death. But having a palliative care doctor assign me this topic to present at our next palliative ward round, I figured it would make for an interesting read.

I was 25 when I witnessed a patient who passed away in front of me. I was still an intern then, and was asked to see the patient in front of many family members. The patient had agonal breathing – periods of deep sighing breathing, followed by long pauses of silence. After a few minutes, the patient stopped breathing at all. Being fairly uncomfortable in such a situation, all I could do at the time was examine the patient, and inform the family that their loved one has passed away.

That was some 3 years ago. I have assessed many more deceased patients since then.

Having used an ebook database, I find out that some of the signs of impending death include:

  • Decreasing cardiac output: increased heart rate, hypotension, cyanosis, mottling, livedo reticularis
  • Renal failure: oliguria, anuria
  • Neurologic dysfunction: decreased level of consciousness, terminal delirium, hypo/hyperactivity
  • Reduced oral intake.

During our palliative ward round, we see a patient who seems to have signs of dying. It was an elderly man who presented due to what appears to be pneumonia. He was drifting in and out of consciousness. He had reduced oral intake. And he looked pale. The man ended up succumbing to his pneumonia, despite IV antibiotics we were giving. Realistically, he didn’t improve after 3 – 4 days of IV antibiotics, and so we had to explain to the 2 daughters that he wasn’t likely to pull through.

I remembered this man from a few weeks back. He was up and talking back then, cracking a few jokes even. I found it hard to believe that he was so well just a few weeks ago.

From what I’ve seen, disease does not discriminate against people. It attacks people of any age.

Breaking Bad News

Having been in oncology/palliative for the past couple of weeks, giving bad news was bound to happen some time.

In medical school, it was always about SPIKES. That’s:

S – Setting – Make sure you’re in the right setting for such a discussion where there is minimal interruption, and plenty of time available for discussion.

P-Perception – Gauge an understanding of what the patient knows to date about their condition so that you know how much you need to tell them.

I-Invitation – This for me seems to be the hardest to get my head around. But the invitation is the time where you essentially ask the patient how much information they want eg “with your recent CT scan, would you like me to tell you everything about it even including the not so nice information, or would you like me to skim through the results and go onto treatment options?”

K-Knowledge – This is essentially the delivery of the detailed information to the patient.

E-Empathy/emotions – Be empathetic and understanding. Essentially, if a patient is crying, offer some tissues. If they look stunned, and shocked, give them some time to process the information.

S-Summary – This is about repetition of the information given beforehand. It’s likely many patients have stopped absorbing information after the initial bad news. Repetition allows them to get the information again.

 

Having been the radiation oncology resident (in addition to the palliative/oncology resident as well – where’s my triple pay?), I was tasked into reviewing radiation oncology patients. There had been this one lady in her 70’s, who had recurrence of vaginal vault cancer, with previous groin lymph node removals for her cancer. She was undergoing radiation therapy with potential curative intent initially.

When the patient was initially admitted under radiation oncology, palliative services were provided, given the patient had pain issues on mobilizing. What didn’t help was this patient had a BMI of 53.

On the palliative ward round, the patient had advised of left hip pain as well. An examination revealed extreme tenderness on passive motion. So a CT hip scan was ordered. And then a CT chest and abdomen were ordered as well (let’s scan everything as well while we’re at it! ). The CT results weren’t good. The left hip pain – completely explained by a pathological fracture at the left hip – specifically the labrum of the hip. And the abdomen – showed that there was a right adrenal gland metastases.

With that CT scan, the patient had gone from “potentially curable” to “incurable”. Of course, being the resident to first see these results, I had the unfortunate job of breaking such bad news. The husband and the patient were lovely people, and were very friendly. Being Italian may have had something to do with it.

So, after reading and re-reading the report numerous times, I prepared to walk over to tell them the results. I was scared though. Scared that I’d break the news terribly. Scared that perhaps the husband might get angry and start shouting at me.

It wasn’t as bad as I had thought, and the patient and husband were very understanding people. On reflection, I don’t think I did invitation in the SPIKES protocol too well. But then, it seems like a really awkward way to ask a patient “if they want to know everything, or only a little of something”. I ended up just telling her “unfortunately, the scan appears to have showed that your cancer has spread to the left hip region, and to the glands sitting above the kidney”. I later explained that given the spread, the prognosis is not too good now compared to her previous well localized cancer.

The husband later ended up telling me how he appreciated my honesty and the straightforwardness of telling them. “You’re not like the last doctors that kept beating around the bush”. Well, I suppose the previous doctors had more uncertainty in breaking the news back then compared to me who had clear results from the scan.

On reflection, I think that it was a very important learning experience. I’m pretty sure as a GP next year, I’ll have lots more of these situations.

You’ll never forget a patient like me

So today, I went on an extra ED shift. I’ve been on Ward Call for the past 4 weeks, but decided on one of my days off, I’d pick up an extra ED shift for some extra pocket money (really helpful when you’re about to go on a date soon).

With the large amount of patient’s you see in ED, one is bound to find a few crazies in there. And today, I found a crazy. Not violent crazy, but pleasant crazy in a way that is just entertaining.

So I see a woman in her mid 30’s present due to a laceration of the right knee. Chased some kids up an escalator, and had a tumble, gashing it open. Why was she chasing the children? I don’t know. But she told me she had some alcohol prior, so maybe it’s alcohol induced laceration.

Anyway, I knew she was slightly crazy when she asked for something stronger than paracetamol.

“Doctor, this is the most interesting thing medically that has happened to me. Can you please give me something strong? Something like pethidine, or some knock out gas would do.”

“Erm…. No. We don’t even use pethidine anymore here in hospital. I can give you some paracetamol and ibuprofen.”

“But, but, I’ve made a massive gash in my knee! Surely it warrants something stronger than paracetamol and ibuprofen!”

“Well, I’ll be putting local anaesthetic in, so that should numb the pain when I stitch it up.”

“Can you please put in like twice the amount usual for your other patients?”

“We’ll see how things go as I inject.”

She later on reminded me a further 2 times about how pethidine or something “strong” would be great for her knee.

And so afterwards, with the laceration exposed after unwrapping bandages, I asked my registrar to cast an eye on it to decide best which stitch pattern to use (I thought I might have needed a vertical mattress, but turns out all simple interrupted sutures were all that were needed).

After my registrar left, the patient said “wow, that doctor looks grumpy. I wouldn’t want him to be doing this procedure.”

Later on as I’m stitching “Geez, that other doctor, is he always that grumpy? He looks permanently angry. He’s actually kind of cute though. Is he single, is he married?”

“By the way, are you single or married?”

Good grief…..

After putting in 8 stitches, the patient thought that falling on an escalator to make the gash in the knee was too boring of a story. So I suggested to her that maybe she could tell people that after having some alcohol, she decided she needed to do battle with the evil escalator, and in the end, knee vs escalator left her knee smashed up at the end.

“Hahaha. I bet you’ll never forget me as your patient. I’m so interesting, and you’ll remember me forever!”

Ha. Yes, she was right. I won’t forget her. But you’ll remembered as that “crazy lady with right knee gash from escalator”. And she gets to be memorialized in my blog as well.

The Legal Responsibilities

The hospital system is the mash up of many different specialties, all with the common goal of patient centred care; people are sick, so they come to hospital to get better.

With these different specialties, comes different responsibilities, and if you overstep your boundaries and encroach onto a different specialty, there are legal liabilities. Hence, a physiotherapists providing medical advice about orthopaedic problems becomes a legal issue.

I understand why there are such legal liabilities, and in fact, I think these boundaries are necessary to protect patients. But having been in the hospital system, I think it can get pretty ridiculous at times. For instance, at the previous hospital I worked at, an ultrasonographer could mark out the level of pleural effusion, but would not mark the spot for fear of legal liabilities should any issues arise if it was drained. Hence the doctor (usually a resident) would need to come and mark the site that the ultrasonagrapher had indicated. So as a result, any issues with a drain insertion would be blamed on the resident, even though it was the ultrasonographer who technically marked out the site.

In a way, I feel that some of these legal responsibilities leads to a decay in upholding good moral standards. The other day I was asked by the nurse to come and console an anxious patient who had her belonging stolen by an outsider. It was a strange request, because what was I supposed to do as a doctor? I felt that a social worker would have been more appropriate. So I arrived and sat at the patient’s bedside, and started listening.

“Ms X, I’m sorry to hear about what happened to you. How are you feeling?”

“I feel terrible. This everything has gone missing including my phone and all my credit cards. I have at least 12 credit cards in my wallet!”

“Ok. Have you started trying to cancel your credit cards yet?”

“I have Westpac here in Australia, and all the others are in England. But I wouldn’t know how to cancel the cards.”

“Ok, maybe I can try and call the Westpac number and we can try and cancel the card.”

I went back to the doctors desk, and asked one of the nurses if social work was doing anything about cancelling the credit cards. Apparently, social work thought it was not their job to cancel credit cards, and declined to help (it was a Sunday anyway).

Anyway, the dect phone I was holding was too unreliable and kept cutting out, so I ended up asking the patient to come to the doctors desk to use the landline. Partway through, one of the surgical doctors asked me to come into a side office. When I got in, she stated firmly “You need to stop what you are doing. It’s not your role to cancel credit cards, and there are legal boundaries in helping her to do so.”

I had a think about this, and could definitely see where she was coming from. It looks sketchy to say the least when a doctor is helping a patient to cancel her credit cards. Almost like I could somehow financially benefit from the situation. I know I couldn’t do much for the patient aside from listening, so I thought the least I could do was to help her cancel her credit card to prevent someone from stealing her money.

In the end, her daughter arrived, and I quietly left the patient in the care of the daughter.

It frustrates me that because of legal issues, it prevents us from doing something decent. It’s something that I hear about to no end in China, where people are too afraid to help people on the streets who are hurt or ill, due to the fears of legal proceedings against them with false accusations.

But then again, in any system, if things like that are allowed to happen, then people end up changing. If the patient made a complaint against me, or if I was penalized for what I did for that elderly woman, I would be pretty stupid to do it all over again if something similar happens.

In the Deep End

I remember my very first formal interview – it ended in failure. What made it so depressing too was that it was THE interview that my future depended on – medical school.

So having failed at that, I realized that either I was an immature 19 year old that lacked life experience, or that I lacked interview experience. I chose to realize the second option, and vowed that some day, I would be great at interviews.

Since then, I suppose interviews just happened. Interviews for entry into the GP program, some interviews for part time jobs. With each interview, I picked up basic skills, such as knowing what to say, and what not to say. I learned to never offer more information then was required to answer a question. And that advice has served me well.

It just so happens that on the 1st of June, all GP registrars could apply to practices for next year, and of course, this would mean submitting a CV, cover letter, and attending an interview.

So in my holiday in China, I spent a great deal of time updating my CV, looking back at the past 3 years and deciding what to put on my CV. I put effort into making it look neat, and to also demonstrate my well roundedness for GP (to my credit, I have done lots of different rotations including surgery, medicine, ED, psychiatry, Paediatrics, O+G and orthopaedics).

Having submitted my cover letter and CV for 5 different practices, I was offered 3 interviews. It was just a matter of preparation.

I think I may have over prepared for these interviews, since I anticipated questions asked, and thought of thoughtful answers to say. And then I reflected on past cases seen, and what I really wanted out of the practices I applied to. And research. Probably the most important thing was knowing about the practice I applied to.

It was a total pain trying to attend interviews when I’m on ED because of the weird rostering. So I ended up attending an interview even though I finished a night of ED. So, I rocked up probably with only 4 hours sleep.

In the end, I managed to get an offer from all 3 places that I interviewed at, which I was pretty impressed with, since I had failed so miserably in my first ever interview. The interviews were so easy compared to what I expected, and I felt a tad silly for overpreparing. But I don’t think one can ever overprepare for an interview.

Again, I stress the importance of research, because I was asked by one interviewer what I knew about their practice. And that’s when I said “I understand that your practice opens 365 days per year, and holds an excellent philosophical principle of providing affordable and accessible health care which is exactly in line with what I believe health care should be.”

In the end, I chose a practice that would be very busy and most likely stressful. But hey, at least I’d learn a lot from it. The supervisor even told me that he would “throw me in the deep end”, so I even got a warning that it was going to be stressful. But isn’t that how one grows and learns, by being outside of their comfort zone? So why not.

Next year’s going to be interesting….. And probably stressful too.