A Medical Student's Apology

We wander around the ward corridor
Chirping, chattering, cheering, conniving
Stealthily we peeked at you
And we thought you would be interesting.

You are awake, you are not sleeping.
You don't have any pain, you are not eating.
You are not demented, and you have got no one visiting.
You look okay, in fact you look welcoming.

We come to you, and start to greet you
The greeting is always the same
Official, boring, and impersonal
And we always go like this

"Hi Mr. Smith my name is Yang,
I am a fifth year medical student.
Do you mind if I spend a few minutes with you,
to talk about your recent condition?"

You agreed to that because you are nice,
But deep inside you let out a grunt.
"Those students again"
"How many of them are out there lurking?!"

"What brought you to the hospital?"
"An ambulance, obviously"
"Tell me more about the pain"
"It hurts, doc"

Minutes dragged on to hours
Hours dragged on to days.
Your stay in the teaching hospital,
Is punctuated by endless visits by annoying students.

At times you see us on the corridor,
Laughing, sniggering, jeering and bantering.
And you probably wonder,
whether we realise we should be a bit more proper.

At times you accidentally hear us say,
"Mr. Smith is an interesting case, go do a long case on him"
And you probably wonder,
whether we realise you are not here for our exam rehearsal.

So an apology this is
For all the patients we have hurt,
For patients we saw as a long case or a short case,
And for patients who are not good for any type of case.

We don't mean to annoy you,
Although at times we probably do.
We don't mean to use you,
Although in reality we probably do.

We empathise what you are going through,
At the very least, we used to.
But after toiling for a year or two,
Even the warmest heart probably turn a bit cool.

My dear patients, we wish we really could
Be a bit less rude and do a bit more good
We are really sorry what we subject you to,
Hopefully, just hopefully, we will all pull through.


Image Credit: Lupus Comedy

Waking Up in a Surgery, Paralysed

Yesterday I came across this article titled "Awake During Surgery" in MX during my ride home. A 24-year-old patient in Northern Territory of Australia woke up during gall bladder surgery, felt every single cut by the surgeon, but couldn't do anything because she was totally paralysed.

Read the news below.

Woman wakes up during surgery
12:00 AEST Tue Nov 18 2008
By ninemsn staff

A Northern Territory woman has endured a nightmare operation at Alice Springs Hospital after she became conscious during stomach surgery but remained paralysed by the anaesthetic.

Rebecca Jones, 24, told the Northern Territory News she could feel every cut of the surgeon's knife during the operation last month but was unable to scream for help as the anaesthesia had paralysed her.

Ms Jones, who was being operated on for gallstones, said she could not open her eyes but could hear and feel everything.

"I thought the doctors had woken me up because the surgery was over — I quickly realised that was not the case," she was quoted by the Northern Territory News as saying.

Ms Jones realised her predicament when she took a breath and found she couldn’t move, but eventually moved her hand to get the attention of surgery staff — to no avail.

"(Someone) said, 'she's just moved her hand' but they kept going," she said.

The hospital's general manager Vicki Taylor admitted to the NT News that Ms Jones had been awake during the operation but denied medical staff knew of her pain.

Ms Jones is now considering legal action against the hospital.

Awareness during anaesthesia may sound like the worst nightmare to most people. Just imagine this. You are helplessly wired up like a spaceman outside a theatre, wheeled into the threatre full of fear of the unknown. Within minutes, the anaesthetist injects some anaesthetic agents into your body, and soon you drift into unconsciousness. Some time later, while you slowly return from the oblivion of anaesthesia, instead of having someone tell you "the operation was successful" like what you see in drama, you actually feel the surgeon cranking and churning your stomach and the anaesthetists discussing today's Sudoku puzzle. Worse, the surgeon might be commenting on your humongous intra-abdominal fat. You lie there, full of fear, wishing this is just a dream but it isn't. Worse, you couldn't move.

Everyday awareness during anaesthesia is experienced by about 100 people in the theatre in US alone. Having had some experience with anaesthesia (I spent one year doing a research in the Anaesthesia department), I am glad I have never come across any horror stories in the theatre. While horror stories like this may deter some people from ever having a surgery in the future, allow me to allay your fear by assuring you that this is very uncommon (only 1 in 1000), and you shouldn't feel any pain even if you wake up.

In the theatre, here are a few things that anesthesiologists / anaesthetists could rely on as an indicator of patient's anesthesia status (from the trivial to the more technical):

1. Patient is not moving. But this is not reliable especially when the patient is given muscle relaxant, as is the case for abdominal surgery like in this woman.

2. Patient's vital signs are not showing sympathetic outflow (BP, heart rate, sweating etc). This could possibly be masked by the other drugs given during surgery. Even if the vital sign changes are noted, it could have simply be perceived as an autonomic reaction towards pain, and interpreted as inadequate analgesia. (Yes your body still react to pain when you are under GA). So the anesthesiologist could have simply given her more IV analgesics instead of checking her consciousness status.

3. The concentration of the volatile agent (gas used to put you under) in the lung, called MAC (minimum alveolar concentration). In most modern hospitals, this is continuously monitored through the anesthetic monitor. Judging from the concentration of volatile agent PLUS opioid analgesics PLUS/MINUS other sedatives (sometimes used), the anesthesiologists have a good indication of whether the patient *should be* asleep.

The problem with this method is that sometimes people have idiosyncratic reaction or tolerance towards particular types of agents, so while statistically a particular combination of MAC and opioid and midazolam could anesthetize 99.99% population, there's no telling who that 0.01% is going to be.

4. Last but not least, an optional (but expensive) monitoring called BIS is used to detect the "brain activity" during anesthesia. This is a series of electrodes attached to the forehead to monitor the electroencephalography (EEG, the "brainwave"). It gives a number from 0 to 100 which roughly translates to the spectrum of consciousness from total brain silence to fully awake. It is not used all the time because of the cost, occasional inaccuracy and the fact that the monitoring above (3) is deemed sufficient.

Regardless of all monitoring and precaution, awareness during anesthesia is a recognised complication during surgery, which, although minimizable, is not 100% preventable. In addition to the idiosyncratic responses mentioned above, in certain surgeries (e.g. in major trauma, elderly patients or pregnant woman) the anesthesiologists in fact go for minimal anesthesia due to their fragile cardiovascular system. So in these population there is a higher risk of awareness, but even for them the risk is about one in a few hundred operations.

Anesthesiologists routinely inform the patients about the risk of awareness when they give consent for the operation. Therefore, though the lady endured a horrifying experience, as long as the anesthesiologists did not make any mistake, she could have simply been unlucky and has no case to make against the doctors.

So go ahead and have your surgeries if you need them. You *should be* in good hands (if you *are* in good hands).

Image Credit: http://www.thesun.co.uk/sol/homepage/woman/article899011.ece

The Irrelevant Question

Me: Is there any disease that runs in the family?

Patient: Ya some angina.

Me: Your parents?

Patient: Ya mum died of some angina.

Me: Did she have actual heart attacks?

Patient: I think so. Died of heart attack when she was 59.

Me: What about your dad?

Patient: Died of old age.

Me: How old was he?

Patient: I think he was about 85.

Me: Ahh ok. You have other siblings?

Patient: No, no kids.

Me: Oh what about your own siblings, brothers and sisters?

Patient: Nope.

Me: Ah okay you are the only child.

Patient: Ya.

Me: So are you married?

Patient: Irrelevant. Next question!

Me: =.=" Oh sorry. Eerm, who do you live...

Patient: Sorry I am a bit tired.

Me: Oh alright, thanks for spending time with me.

U R...

In Royal Melbourne Hospital, there is this patient registry where every patient is identified with a reference number. The reference number is called the "UR number", which I believe stands for "Unique Registration number".

So one day, I was visiting a ward to look for a patient.

Me: Hi I am looking for Maria Levoski, may I know which bed she is in?

Ward Receptionist: *flip flip flip*

Ward Receptionist: I can't seem to find her now. Let me page the bed manager.

Ward Receptionist: *Open the software for paging and start typing out a query for the bed manager*

Ward Receptionist: You are?

Me: My name is Yang.

Ward Receptionist: No I mean the patient's UR number.

=.="

Image Credit: AP Photo

Names That I Respond To

1. Chang*
2. Yang**
3. Chang-Yang***
4. Chang (awkward pause) Yang
5. Yew
6. Yong
7. Chang Yew
8. Yew Chang
9. etc etc.

Living in a Western country forces one to respond to all sorts of distorted pronunciation of your name, especially when the words are not quite "Anglicised".

* Calling me Chang alone with the right pronunciation (the Malay pronunciation) used to be enough to annoy me. It got worse when people started rhyming it with "hang".

** And then, some doctors here decided to call me Yang with the rhyme of "hang" too. >.<

*** The ultimate version is to combine the two words with the incorrect pronunciation.

No, I will not succumb to crafting an English name in order to "make it easier" or make myself "blend in" better. I guess I should just get used to my names.

By the way, I am not the only victim of funny names. Xuan Ni has heard at least a dozen different pronunciation of the word Xuan. One of the Chinese doctor with the surname NG sometimes got referred to as "Doctor N-G". Poor thing.

Two-Thirds Majority

To those who think I am going to write "yet another" grandmother-tale political commentary, please be glad that this is not about politics.

I am talking about my research project.

I started my research project back in late August last year, and it's been going on non-stop since except for my one-month holidays in Malaysia in January and February. For my research, I have to get 70 patients in order to obtain statistically significant result. Or in other words, 70 patients are required so that my finding is going to "hold more water" from the rigorous scientific point of view.

And after 5.5 months of recruitment, I have only got 48 patients, which is barely over two-thirds of what I need. And I have only about 1.5 month left for my recruitment, after which I must concentrate on data analysis and report writing.

I am also the only person in my batch (I think) who has to go in the hospital at 7 every morning (in order to "catch" the first patients having operation), but I am not going to finish my project.

Arrghh. Such is life.

What I Did Today

I grabbed an old guy's penis, cleaned the glans ("turtle head" in Chinese), chucked a whole lot of gels up the urethra, then inserted a foot-long rubber tube into it.

After that, I injected a bit of water to fill up the bladder. And when I pulled out the syringe, some fluids sprayed onto my arm.

I hope that it's the water.

A Special Patient (4)

This post is a continuation of an earlier post.

As Maria started complaining about feeling sick (nausea), the nurses were very worried. The feeling started around the same time as we gave her morphine for pain relief, so they were suspecting that the morphine caused the nausea. Aih, those anaesthetics and analgesics are all funny unpredictable things, for the same kind of drug some patients deal with it just fine, feeling all comfortable and easy; but some patients flush, throw up, feel drowsy and get funny feelings in the head.

When Maria started complaining, my heart screamed "DAMN!". Look, I waited for the whole day since early morning, and at that time it's already near 7pm. I had also already spent half an hour setting up the patients with the belts, wires, monitor and all the fancy stuff. If the patient turned out to have allergy or adverse reaction to morphine, that meant I must cancel this patient, and all my effort on that day would just go down the drain.

Also, do you remember how I mentioned that I had not-too-good good first impression about the patient's history, with her smoking marijuana everyday since 13 and all? If she's feeling uncomfortable, just imagine if I continued to strap her up with those equipments, she might actually go find her "bad" friends and beat me to death. Okay I am exaggerating this, but my worry about the cancellation was real. It's simply a major pain in the ass whenever I have to wait for the whole day but end up with no useful work.

The nurses called the consultant to see whether it's okay to change the morphine to other pain killer. If they changed it, I was basically screwed since my research requires morphine to be given. Turned out that the consultant decided to change the morphine to a morphine-related pain killer called fentanyl which has a lower incidence of adverse reaction. The nurses told me, "Sorry, I think you can't do this patient this time."

Determined not to give up, I called my supervisor to ask whether it's possible to continue the study. To my delight, he said YES!! What happened was, in my research we were supposed to keep track of the morphine and analyse its effect on the obstructed breathing; so in this case, although they changed it to fentanyl, we could still convert the fentanyl to its "equivalent dose" of morphine and perform the same analysis. That meant my effort was not wasted after all!

So I went back to the bedside, but unfortunately the patient was still in clear distress. Just as I was figuring how to tell her "Hey despite your discomfort just now, we are still going to do the research anyway", she told me something that I will never forget:

Hey I heard that you can still do the study? I am really glad that you don't have to cancel the study! I really want to help you with this. I am a market surveyor and I know how important research work is to us.

Imagine being so magnanimous and helpful when you are feeling so nauseous. Can you do the same thing? I was so touched and grateful I was brought to the brink of tears.

Maria will always remain one of the most special patients I have ever had. She taught me so much about medicine, and how bad it is to let first impression cloud my judgment. Those things, we don't learn from textbooks.

A Special Patient (3)

This post is a continuation of an earlier post.

Me: So would you mind to participate in it?

Maria: Yeah sure! Since I won't be doing anything else anyway. How long do you think I am gonna wait for?

Me: A couple of hours or so... I can't be sure because the operation time is quite variable. I am sorry about that.

Maria: It's alright.

I am surprised at her lack of anger or disappointment, given that she thought she was going to be called in for surgery earlier when I was calling them.

With her agreement, we proceeded to the documentation, went through some details like the possible benefit of the research, possible risks, and signed the form.

I went to the anaesthetist and then told him that Maria has given me consent for the study. I handed him an envelope which was chosen in random, and in that envelope was the pain killer she is supposed to receive for the purpose of our study. Rest be assured, all the drugs are safe and used in the hospital all the time (that's what I told the patients all the time anyway :P).

So she went in for the operation later, and at about 6.30pm she was out from the theatre and sent to the recovery room. When I first entered the recovery room, the nurse told me, "Eerrm, it's not the best time to talk to her. She seems a bit upset."

She was more than a bit upset.

She seems quite frustrated as she closed her eyes and wriggled about on the bed and whined like a child throwing tantrums. Whenever the nurse tried to talk to her, she waved her hands and whimpered incessantly. It seems terribly difficult to approach her, not to mention set up the sleep monitor on her.

So I waited there for her to recover. I assumed that she was only whimpering because of pain, but the nurse told me that she doesn't have much pain at all, she's just getting upset for no reason. Weird isn't it?

After some 15 to 30 minutes, she gradually stopped tossing and turning, and I decided to approach her and begin my work. Surprisingly she was pretty friendly and cooperative. She just kept saying "Yeah sure" when I asked whether I could do something.

So I started setting up the stuff one by one:

1. Stick a little oximeter probe (blood oxygen sensor) on her index finger.
2. Stick electrodes on right collar bone, at the skin upper right to the right eye, lower left to the left eye, behind the right ear, and at the 10 o'clock direction of the scalp.
3. Attach the nasal prong.
4. Tie up two belts on the chest and the abdomen.
5. Attach the nasal prong and wires of all the probes and sensors to an electronic recorder.
   

But something wrong was happening. She started to complain about feeling sick (nauseous) and she wanted to vomit.

[To be continued...]
[20 Dec: Continued and completed here]

A Special Patient (2) - About My Research

This post is a continuation of an earlier post.

This is a conversation between myself and a patient, and it kind of explains the research I am doing since I am giving explanation to the patient in layman term below.

Me: My name is Yang, and I am a student doctor in Anaesthetics department. How are you today?

Maria: Good! But hungry, really hungry.

Me: Hah I am sorry about that... they like to starve the patients, don't they? :) So... you are having a surgery on your back today, and after the surgery you are going to stay in the hospital for a few days.

Maria: Emm hmm...

Me: We are a bit concerned about the pain killer's effects on the patient after the operation. For your operation, you will receive a routine pain killer after the operation. Those are really good drugs, but from our experience, it sometimes cause a bit of obstruction in breathing, especially when you are sleeping. Do you have a bit of snoring when you sleep, by the way?

Maria: Yeah sometimes, especially when I am tired.

Me: Yeah snoring is a kind of partial obstruction too. Those obstruction aren't exactly dangerous, as you would gasp for more air naturally when you don't get enough of it. But after an operation, the obstruction is not good for the recovery because you don't get enough oxygen when things get obstructed. So now, we are having this investigation, or research, to investigate the effect of pain killer on breathing. We kind of identify patients who we think are at a higher risk of obstruction, and since you have a high weight and you do snore, we think that it's good for you to be part of the study.

What we are doing is, if you agree, after the operation, we will put a couple of bands which will go around your chest and the abdomen, a tube which goes below your nose, and a few wires. (see picture) What they will do is to record your breathing at night, and on the second morning, I will take them off at about 8 o'clock, then use the computer to analyse the result. If we do find serious obstruction, we will refer you to a doctor.

And oh yeah, for this study, you will be given one of two types of pain killers after the operation, one is morphine, another is a drug called tramadol. You will be given a button to press which will give you a dose of pain killer when you need it.

So, yeah, that's basically what the research is about. So would you mind to participate in it?

[To be continued...]
[26 Nov: Continued here]

A Special Patient (1)

I had a special patient today. Let's call her Maria.

Maria is a 21-year-old lady who's coming in Royal Melbourne Hospital for an operation called "Lumbar Discectomy". Basically, it means that she's fixing a disc which had slipped out of its usual position between two bones which are located at her lower back. The displaced disc (see figure - the blue thing labelled L5) impinged on her nerves, and has produced pain on both legs, and it's especially worse in the right leg where it expands throughout the whole length. The pain of this nature is usually referred to as sciatica, as it's usually associated with problem with the sciatic nerve (the fat nerve going down the leg in the figure).

Guess what: Maria has had this problem since she was 12.

Maria's predicament remained undiagnosed because it's rare for young people to get sciatica, which is quite common among older population. Throughout the years, doctors had been telling her that the pain was due to muscular problems, and that it would become better with time. It was not until last year when she couldn't bear with the pain anymore, that she asked for another check-up and discovered this problem. Turned out that she had a really severe case of disc prolapse, and if it's not fixed urgently it would progress to a medical emergency called cauda equina syndrome.

So I had a look at Maria because she was suitable for my study. From her history, I discovered a couple of interesting things:

• She had been smoking cigarette since 12 year old.
• She smokes marijuana (weed, 大麻) everyday

If you tell one of the more conservative parents only these information, my bet is that they are going to flinch right there and then while the image of a samseng girl is conjured in their mind. To be honest, I had a bit of hesitation too - is she going to be that kind of violent, uncivilized people?

I mustered my courage to approach her for my study. I stood there and called her name out loud in the waiting lounge, and the girl with her mum and her partner stood up and came to me cheerfully.

I thought:

Shit, they thought I am going to call her in for surgery preparation while I am only inviting them to participate in the research. Damn damn damn. They are going to be so mad at me. She's hungry (patients need to fast a long time before their operation) and impatient and all, and now I am going to invite her to be some sort of research participant. I am so dead.

So I showed them to the interview area, my heart pounding real hard as the family remained cheerful.


[To be continued...]
[19/10/07: Continued here]

At the Hospital Entrance

Everyday I enter the hospital early in the morning and leave for home in late afternoon. There's this hospital main entrance which I pass through everyday. Guess what I see every time as I pass through that area?

Smokers.

Or to be precise, a number of patients, some on wheelchairs, some with their drips on, who come out to have a puff.

Also, the ground in front of the hospital is littered with cigarette butts.

Isn't it ironic?


p/s: I have no prejudice against smokers (in particular, their choosing to smoke / not able to pull out from the habit despite knowing the adverse effects). This post is just reflecting on the irony of having smokers crowding a hospital entrance. I am in no way judgmental towards patients based no their smoking habit.

Ever Wondered What Anaesthetists Really Do?

This is the absolute answer: (Winson, you will like this)

Everybody wonders what anaesthetists do
While the patient is asleep
Everybody wonders what we do for three hours
While the machine goes beep
Everybody reckons we drink coffee and we gossip and we're generally subversive
Everybody reckons we do crosswords and Sudoku and we chat up all the nurses

But do you really think that's all we do
Well let me tell you now isn't true...

'Cause we sometimes check the screen
And every now and then we write stuff
And if we have to intervene
We inject a bit of white stuff [propofol]
And we offer to alter the lights
Or the height of the bed
Or fiddle with the radio, change the CD
We even check the patient occasionally...
And if they move, we turn up the vapor,
And then we go back to reading the paper

'Cause when the patient's asleep
We just sit and listen to the beep
We just sit and listen to the...

Once upon a time I took pride in my job
But now I think it's time to depart
'Cause I just sit here everyday
And listen to bleeps of the heart

Having spent some time in surgery theatres with anaesthetists for the past few weeks, I can personally confirm that the description is accurate. :P

More medicine craziness to follow - "The Drug Song":



And finally, we have the ultimate "wonder drug" - Paracetamoxyfrusebendroneomycin!

Paracetomoxyfrusebendroneomycin,
It’s our brand new wonder drug we think you’ll find enticing,
Paracetamoxyfrusebendroneomycin!

Um-diddle-iddle-iddle-um-diddle-ay
Um-diddle-iddle-iddle-um-diddle-ay
Um-diddle-iddle-iddle-um-diddle-ay

The BNF has twenty thousand different drugs to take,
So we thought, “What could we produce to give you all a break?”
A drug that could treat anything from leprosy to SARS,
And you can give it in the mouth, IV or up the arse.

It’s Paracetomoxyfrusebendroneomycin,
Paracetomoxyfrusebendroneomycin,
It can cure the common cold and being struck by lightning.
Paracetomoxyfrusebendroneomycin!

Um-diddle-iddle-iddle-um-diddle-ay
Um-diddle-iddle-iddle-um-diddle-ay
Um-diddle-iddle-iddle-um-diddle-ay

We tested it on animals and none of them survived,
But that’s OK cos when we wrote the paper up we lied.
It first choice for MI, MS and even for ME and COPD, HIV, PE and DVT

Paracetomoxyfrusebendroneomycin,
Paracetomoxyfrusebendroneomycin,
It reverses impotence and makes you good at fighting,
Paracetomoxyfrusebendroneomycin!

Um-diddle-iddle-iddle-um-diddle-ay
Um-diddle-iddle-iddle-um-diddle-ay
Um-diddle-iddle-iddle-um-diddle-ay

There are some minor side effects and some are not that rare,
Like nausea, vomiting and losing all your hair,
And heart attacks, becoming gay and growing extra breasts,
But it’s fucking cheap, and hey, this is the NHS.

Paracetomoxyfrusebendroneomycin,
Paracetomoxyfrusebendroneomycin,
There are cures for everything from AIDS to pubic lice in
Paracetomoxyfrusebendroneomycin!

Um-diddle-iddle-iddle-um-diddle-ay
Um-diddle-iddle-iddle-um-diddle-ay

Paracetomoxyfrusebendroneomycin,
We make it from the cerebellar cortex of a bison.
After that it undergoes some polygenic splicing,
Paracetomoxyfrusebendroneomycin!

Um-diddle-iddle-iddle-um-diddle-ay
Um-diddle-iddle-iddle-um-diddle-ay

Paracetomoxyfrusebendroneomycin,
It makes you smart as Einstein and as muscular as Tyson.
It brings an end to all that pharmacology revising,
Paracetomoxyfrusebendroneomycin!

Um-diddle-iddle-iddle-um-diddle-ay
Um-diddle-iddle-iddle-um-diddle-ay

Paracetomoxyfrusebendroneomycin,
We sell lots in Japan cos it’s the antidote to ricin.
The minister of health we hear will shortly be advising
Take Paracetomoxyfrusebendroneomycin!

Earlier than Expected

From the day I chose medicine as a career, I have always known that the road ahead would be challenging. Long working hours, stressful environment, distressing tragedies are just a few examples in the long list of adversities faced by healthcare workers. Certainly most people would reap the reward at the end of the day, but concealed from the pride and glory is the sweat and tears as they grudgingly put up a positive front to their colleagues and patients on every single day.

Don't get me wrong here - I am not saying that being a doctor is a bad job. In fact I have been exaggerating the hardship here for the sake of drama. For the past few weeks, watching surgeries, appreciating the marvel of technologies, learning new stuff, talking to doctors, seeing real alive patients (yes you hear it right) have been some of the most rewarding moments since I entered medical school. At the end of each day, Xuan Ni and I usually exchange our daily experiences and stories while walking home along Grattan Street, and that have been been thoroughly enjoyable. We commiserated with the unfortunate cancer patients, tipped off each other about cute doctors, and assuaged each other's complaints as we shuffled home tiredly. And that, I must say, is the highlight of my days.

But still, everything came earlier than expected.

I knew that the future that awaits me are the 36-hour shifts, endless walking in the hospital and breathing in medicine-scented air. But I never knew that busy days have begun to take its toll on me, and such schedules will probably remain until I retire in the unforeseeable future.

I knew that at some point in my life, I will no longer have the freedom of surfing online until the wee hours in the morning - but I didn't know that in order to wake up at 7 everyday, I have already been robbed of that freedom in the third year of medicine.

I knew that I have been living an obscenely slack lifestyle throughout the years, and that it ought to be substituted by the harsh medicinal lifestyle. But I didn't know how a research student's lifestyle could be so much more demanding than the lifestyle of a pre-clinical medical student.

Probably I never knew well enough.

I never knew how lazy I have been for the past 21 years, that even a mildly disciplined lifestyle seems like a punishment to me.

I never empathized enough when my architecture friends complain about sleep-deprivation. Until I begin to sleep less than six hours everyday.

I never knew I am not as adaptable as I thought. When it arrived earlier than expected, I flounder. But I will move on toughly. The only way to go through a hardship, is to move on.

[CNN.com] Why They Told You to Think Twice

(CNN) -- "Two minutes!" yells our course coordinator.

Medical student Emily Breidbart joins her anatomy lab partner, Jonathan Adelstein, on the last day of class.

Her voice startles me as I try to concentrate on Mrs. Chin's account of her recent asthma attacks.

I have already used eight of 10 allotted minutes, and now have to wrap up my "Objective Structured Clinical Examination."

During our four years as medical students, we will do dozens of these OSCEs -- imaginary, but realistic doctor-patient scenarios.

My professor praises that I structured my 10 minutes well. I'm pleased. In our first year, we simply take a medical history. But next year, I'll add a physical examination, and in my third year, I'll be adding counseling and treatment into the "patient visit." And all we get is five more minutes added onto our OSCE time. How can I get all of this done in just 15 minutes?

Learning how to practice medicine on this sort of a time-scale is stressful. But it's totally necessary in order to properly train us for a world of health care in which the average physician visit is six minutes! When our professors went to medical school, they were taught the art of healing; we are taught how to diagnose and treat patients in a limited timeframe. I can't help but think, is this what I signed up for?

My father is a pulmonologist and the head of an eight-doctor practice on Long Island. When I tell people this, many say, "Oh, he must have really wanted you to follow in his footsteps!" But actually, he made me very wary of medicine. He is tired of spending half of his energy dealing with insurance companies. Energy and time, he says, that would be better spent on his patients, time he had when he first started practicing in a health-care era in which doctors didn't need to justify prescriptions and tests to insurance companies. He still insists on giving ample time to his patients, but now has to work incredibly long hours to do so.

At my dad's 50th birthday party, when I was 19, his colleagues interrogated me about my recent decision to pursue medicine.

Are you sure you really want to do this?

Why put yourself through all the years of stress? You're a smart girl -- how about journalism, law, business...?

Your dad couldn't convince you not to do this? I'll have to have a talk with him!

How is it that my classmates and I are going into medicine if this is what people who have lived our future are saying?

We start out in medical school as idealists. We thirst for clinical experience. We want to explore all of our options, and help those who can't afford health care. But somewhere along the line, we start taking off our rose-colored glasses. I've seen it happen already with some classmates after only one year of school. We know that it is surgeries and procedures that are financially rewarded. Insurance companies reimburse very little for routine examinations. So although we might really be interested in primary care or pediatrics, after hundreds of thousands of dollars of debt (my school estimates that each year, tuition, housing and expenses will cost about $55,000), many of us feel pressured to go into a specialty field that will ensure we can pay back our loans. Our dreams and good intentions have to be put aside.

And then there are fields like OB-GYN, which a lot of my colleagues have already ruled out because of the high cost of malpractice insurance.

We are taught about malpractice from Day 1. I remember countless times in the anatomy lab when we were digging for arteries and nerves, our teachers saying, "Now if you cut this in real life, you would be sued," phrased in terms of a legal consequence instead of the repercussion that the patient might die.

This "art of defensive medicine" infiltrates the classroom too. We are taught how to ask questions of our patients and treat them in such a way that minimizes our risk of a lawsuit. We are trained what kind of patients to be wary of. Basically, we are taught that we can't trust our future patients, which is confusing to first-year medical students. How can we expect our patients to trust us if we can't trust them?

Yet, after all this, I'm truly excited to be a doctor. Medical science and technology are booming and there will be so many ways in which we can help our patients. I want to go into pediatrics, and can see nothing more rewarding then helping sick children. And I can't blame the medical school curriculum; it is only preparing us for a reality. It is my hope however, that in my lifetime, our health-care system will change in such a way that lets us go back to simply learning the art of healing.

From: CNN.com

My Little WTF Moment

Update 09/08/07: Here.

Today is quite like other AMS working days, but unlike other peaceful times, today was marked by a little dose of WTF moment.

The story goes like this: Our supervisor wanted us to shadow (= tag along) an anaesthetist, and after some arrangement he decided to take me to an anaesthetist (call him Z) who's doing anaesthesia for endoscopy procedure. While the supervisor was bringing me to the procedure room, we met Z who's leaving the endoscopy area. My supervisor asked Z whether it's alright if I shadow him, and he said fine, and he would be back soon. The supervisor told me to wait at the procedure area, as Z will be back in a second.

So I waited there. Standing has become a routine for me for the past few weeks. I stand most of the time when I am in hospital watching surgeries and other stuff. At times I feel stupid as I can't do much in the hospital. We do so much waiting all the time, most of the time waiting for someone to come back while we are left hanging around, not being told what to do or expect, simply being useless. While I am waiting, I could just stare at a blank space, or sometimes I take out my PDA to do some brief reading.

After 5 to 10 minutes of waiting, he's not back and I had a call from nature (which happens quite often to my for some reasons). So I went to the washroom, quickly finished my business, and went back to wait. After some 5 to 10 minutes again, I decided that it was too long a wait, and I did what everyone would do - I asked a doctor at the receptionist area. The doctor told me that Z is already in the procedure room, and I can just go in there.

Me: Dr. Z?

Z: Oh hi! *walk towards him, who's prepping up the patient for the endoscopy*

Me: Is there anything I could help?

Z: You are late.

Me: I waited for you outside but you weren't back. Then I went to the toilet and waited again. You might have come back when I was in the toilet. (Can't really remember whether I said sorry at this point, but I did say sorry once at one point in this conversation)

Z: No I do not accept this excuse. This is a really bad excuse.

Me: Really I was outside... (I might have said sorry at this point. Again I am not sure)

Z: You could have come in and looked for me. Really if you don't want to be here you don't have to.

Me: I want to be here.

(Can't really remember what we said after that. The conversation stopped around that point.)

And he almost ignored me throughout the whole 2-hour session. He just talked to me twice.

I realize that I was partly at fault for being late, as when I came out from the toilet I should have just gone to the reception and asked about Z's whereabout, instead of assuming that he wouldn't have gone in within the 2 minutes I spent in the toilet. It's my judgmental error and I should really have done better than that.

However, I couldn't stomach the judgmental attitude he cast upon me. The way he looked at me ludicrously and almost sneered at me when he replied to my excuse, showed that he thought I was telling a very bad lie, or some sort of bad jokes. The remark "you don't have to come if you don't want to" was put in an extremely bad taste too. Just imagine, having stood and waited patiently for someone for almost half an hour, and all you get in return was a mean remark of "you don't have to come if you don't want to". Let's talk about intention and outcome, eh? We need more communication, doc.

Sigh. It's lucky that the majority of the doctors I deal with aren't that grumpy. Many of them are willing to share their knowledge enthusiastically and patiently. I won't keep this in mind for long, but I just hope that there will be less judgemental people in the world. Getting worked up for an innocent misdoing, and being judgemental towards people, is bad for oneself and for other people.

Update: After some considerations and some inputs from friends, I do think that I might have been responsible for the whole episode. Despite being innocuous, what I should have done was to say sorry when he first said "You are late" (which I didn't say until the second or third verbal exchange). I didn't say sorry at first because I didn't assess it as something requiring apology when he worded it, and also because of my recently acquired defiance of not apologizing when I reckoned something was not done intentionally. And that defiance has misfired badly, despite my apologizing later when he was already frowning upon me. For Z, I could have seemed like a delinquent student who's not apologetic despite being late, and hence deserved a good reprimand. And it's my fault for not showing my sincere, innocent, lovely facade. :P I shoulder the responsibility, admit my error, and would learn to say sorry in the future.

Image credit: 2point Portfolio