Day of Reckoning

This is it: the result of four years of formal medical education all hinges on our performance in three hours this afternoon. The sixty or so of us taking the exam this afternoon get to the hospital and wait around the lobby to be called in. We are then herded into another room, wait some more. The room is humming with anxiety; some of us chit chat to distract ourselves while others flip through pages of notes. Psychogenic diuresis kicks in, we drink more water; the toilet is in constant demand. After an eternity, we are lead out of the holding room to our respective stations. At the sound of a buzzer, the exam is officially started.

Three hours later, the last buzzer is accompanied by a collective sigh of relieve from all of us. We stream out of the hospital, some recounting the points they failed to make, some swearing they will be blind drunk tonight. I am just happy the whole thing is over.

In the evening, I join my fellow classmates at the Royal Exchange Hotel, the local watering hole frequented by college students, for a night of celebrating the end of medical school and, for many people, to say good-bye to each other. Soon enough, we will all head our separate ways.

We greet each other by a hearty “Congratulations, Dr. [insert last name]!” and point out the novelty of being called doctors. When used in front of my name, it still sounds so oddly formal. With beers in hand and over the amped up guitars by a cover band, we talk about where we will be next year, what specialties we want to go into, and the possibilities the future might bring. The buzz goes late into the night.

We have done it! I have done it! It feels surreal – to not being a student anymore, to not having to worry about studying tomorrow, to finally have a job again.

One Day More...

Until this is all over! The big, end-of-medical-school-and-must-pass-to-graduate exam is spread out over today and tomorrow. Our class is split into four groups: Saturday morning, Saturday afternoon, Sunday morning, and Sunday afternoon. As always in this kind of situation, I have the misfortune of being allocated to the Sunday afternoon session, just to ensure that the agony of endless waiting is prolonged. The exam is the live, face-to-face type consisting of nine live stations in which we are given scenarios and are instructed to talk to or examine or device a management plan for the real or volunteer “fake” patients.

By now, half of the class has already finished their exams. I am sure they are all appropriately in an altered mental state, but continue to quaff large quantities of alcohol in various disguises which, for many, has been the one constant through the four years of medical school.

While those half of the class are blowing off steam and generally engaging in wanton revelry in ways that may potentially be career-enders should they wish to enter politics later in life, this half – well, me at least – is trying to use our psychic power to predict the questions and topics that will be on our exam tomorrow. They had a cardiovascular system examination station today? I think it might be respiratory or gastrointestinal system tomorrow. They had an O&G station consisting of contraception advice and placenta previa today? It could be pre-conception counseling and pre-term labor tomorrow. Today’s ophthalmology station had patients with glaucoma and retinitis pigmentosa? We’ll probably get a couple of patients with macula degeneration and diabetic retinopathy…

No more studying. I am as ready as I will ever get. It’s time for some sleep.

Turkey of a Day

Happy thanksgiving! Hope your turkey is delicious.

Because I’m not having any.

I’m getting used to doing nothing for Thanksgiving now. For one thing, in Australia, today is just the fourth Thursday of November and nothing more. Secondly, we have our big, end-of-medical-school-and-must-pass-to-graduate exam this coming weekend. Any holiday would have to take a back seat to studying. For the last few days, I have set up shop in the library with my study group, pounding the past exams. And today was no exception.

So I came back in the evening, cooked up some quick pasta, and called it a day.

Maybe I can do some kind of Thanksgiving dinner next year.

Ten for Ten

In the early afternoon, I walk out of the children’s hospital with the other student in the rotation, feeling tired but relieved. Now that the exam for pediatrics is behind us, what are we going to do?

First, a beer is essential. Then, I am just going to enjoy the sunny afternoon.

Next week is study week for the big exam: everything we have learned over the last four years will be fair game. The diploma is going to be hinged on whether we pass this exam. So, the pressure is on.

But for this afternoon, I’m not going to think about it. Maybe I’ll even go see that new Bond movie tonight.

All Studies and No Exercise

Ugh, I feel like my body is atrophying. This is the last week of the rotation, which means serious study time, which is encroaching on my exercise time. For a whole week now, the only exercise I have been getting is my bicycle commute to and from the hospital. At a measly seven kilometers roundtrip, the commute is long enough to make me break a sweat, but not long enough to make me feel like I got a workout from it. Well, it’s better that than nothing.

Downed by Germy Kids

Everyone else on the pediatric rotation has been getting sick. It seems that whatever virus the sick kids have been coming into hospital with, it is now being passed around our group of med students. A few of my compatriots have already been feeling miserable as of late. Amidst the constant sniffling, I have luckily avoided getting hit - until last weekend. A hint of a sore throat on Friday brewed over the weekend and, by today, has become a full-blown case of viral upper respiratory tract infection. This has got to be the worst time to be sick. There are only two weeks until the end-of-rotation exam and then another week until the final exam. I really can't afford to be sick this close to two important exams. I know it's probably viral and I just have to let it run its course. If it's caused by what the kids have been spreading around, I should be feeling pretty sick these couple of days but I will be fine come exam time. Let's hope it's that and nothing worse.

Playing House

During a teaching session with one of the pediatricians today, I felt like we were the characters on House.

We saw a thirteen-month-old baby girl who was admitted to the ward yesterday. Through her mother, we learned that the baby had a previous history of Hand, Foot and Mouth Disease, which is a viral infection that happens commonly in children. It ran its course and she got better. Then her mother noticed a rash and diffuse redness in the area covered by the diaper. The mother treated it like a diaper rash. After a couple of days, the baby had not passed any bowel motion and was crying incessantly. The mother thought she had constipation and gave her some enema. The baby opened her bowel but was still unwell. At this point, the mother noticed that one of the baby’s legs was swollen from the hip to ankle and that she was spiking fevers intermittently. The mother finally brought the baby in to the children’s hospital Emergency Department. After having five different doctors taking a history from her, the mother clued in to the fact that the doctors were suspecting a non-accidental injury – i.e., child abuse. After a skeletal survey of the baby turned out normal, more investigations revealed the final diagnosis: the baby had septic arthritis of the hip. Ok, so the diagnosis was not House-worthy, but the process just made me think of the show.

There we were, three med students taking turn asking the mother the history yet again. Each time we were lead down the garden path, only to find that each piece of new information made us do a complete U-turn and think about a different process. Sure, all we did was take the history, we didn’t do any of the crazy things on House like going to the patient’s home and digging up the sandbox (as if doctors really do that in real life). Unlike House, our clinical coach, the pediatrician, was actually very nice to us and to his patients. So maybe it wasn’t like House after all, but I really enjoyed the exercise.

Going into the rotation, I didn’t think I would like pediatrics that much. But I think it’s growing on me.

Baby Check

I enjoy going to the neonatal ward. With all those chubby newborns and happy parents around, you can’t help but smile and share their joy. Yesterday I followed a resident on the ward and did a few well baby checks, which is one of the skills we have to learn during this rotation. Before each newborn is discharged, they are given a once-over by a doctor to make sure they are normal beyond having ten fingers, ten toes, and no obvious deformities.

Like everything else in medicine, there is a system to doing a baby check. You literally go from head to toe and front to back to examine the baby. I especially enjoy doing the primitive reflexes like the grasp reflex in the hands and feet, a telltale sign of our arboreal ancestry, and the Moro reflex, which is believed to be the only unlearned fear in the newborn. Today we had our baby check skills assessed by the neonatal consultant. The way I interacted with the baby I checked must have looked really natural, the consultant asked me afterward if I have kids of my own. Well, besides the four babies I delivered during the O&G rotation, yesterday would have been the first time I handled newborns. So maybe I do have a knack for handling little babies.

Kids Emergency

This week I am rostered on at the Emergency Department. Over the last couple of years, I have been slowly developing a liking to emergency medicine. Even though it is not always the adrenaline-pumping full-resuscitation cases with patients bleeding profusely as doctors bark orders while jumping on the patients’ chests as the stretcher races down the hall – in fact, that’s rarely the case – I really like the variety of presentations that’s characteristic of the specialty. So, I really look forward to my week at the children’s emergency department at the hospital.

Today I am on from 3 pm to 9 pm. This being my first day, I am still trying to find my way around the department. The consultants and registrars are incredibly nice to us. I have noticed that all the pediatricians I have met so far have been good teachers and really pleasant to work with. It makes sense: in order to be able to get kids to cooperate, the doctors just have to be pleasant to work effectively. It is hard enough to get kids to cooperate during examinations, a grumpy doctor would basically make that an impossible proposition.

The kids around Brisbane must have had a rough weekend. Late in the afternoon, the waiting room is filled with kids with various injured joints. As a medical student, all I can really do to help out the registrars and residents is by seeing the subacute cases: a sprained ankle, a swollen thumb, a rugby-related knee injury… Before long, it’s nine o’clock – the end of my shift. I have not had dinner, but I don’t even feel hungry. Normally, by this time, my thought would be on nothing but food and I’d be gnawing on my pen already.

“You coming in tomorrow?” the registrar asks me. “Yeah, three to nine again.” “Good, I’ll be on in the evening again. See you then, I’ll get you to do some good work.” With that, I change into my cycling clothes, hop on my bike, and ride down the quiet road toward home.

Pre-Approved Straightjackets

Seeing how all of us are going to be doctors and earning an income in little more than three months, the university medical society organized a “Finance Evening 2008” tonight in case we don’t know what to do with all these money we’ll be making.

We gathered at the auditorium. A bunch of people in spiffy pin-striped suits took turn and gave us talks on the ins and outs of managing personal finances and services their companies offer. New words were being thrown around: salary packaging, superannuation, negative gearing, capital protected borrowing… I’ll have to look up these words later, but I did learn that, apparently, there are so many ways for these companies to minimize our taxes – and they are all legal. I’m listening, tell me more…

In the middle of their talks, almost every company told us about these pre-approved lines of credit up to $10,000 sitting there waiting for us as soon as we start working. And then there are car loans and 100% home loans. They are practically throwing money at us. I guess the credit crunch in the US has not come across the Pacific yet. Some may salivate at these “generous” offers, but, to me, each one of these pre-approved loans dangling in front of us looked like someone holding up a straightjacket, just waiting for us to turn around and put our arms through, then ziiiiiiip, we’re trapped for the next thirty years. I am already graduating with a bunch of mortgage-size student loans; the last thing I need is another loan on top of it, no matter how favorable the terms may appear to be.

So, no, I don’t need a new car, my little three-cylinder Daihatsu with 240,000 km on it will do just fine, until it dies. House? I’ll be okay living in my rented hovel as long as my net worth is in the red. No, I don’t need a line of credit either. Now, about that tax minimization…

The Beginning of the End

Yes, it’s the last rotation of medical school! But, sigh, it’s arguably also the toughest one – pediatrics. It’s like everything we learned in the last two years all rolled into one: internal medicine, surgery, psychiatry, emergency medicine, and all those subspecialties like nephrology, cardiology, radiology, and whatever-else-ology. I thought the O&G rotation was busy, but by the looks of it, this rotation is going to be full-on. Goodbye, weekends.

Nine Down, Just One More To Go

Yes, it’s done! The exams are over! Now I have a week off.

Hmm, I forgot to plan something for next week. I guess I’ll have to sit around, twiddle my thumbs, maybe read a book, have coffee with friends, do some bike riding, and generally do nothing.

Yeah, that sounds like a plan.

I want It Over Already!

The rotation is coming to an end. Exams for this rotation are going to be in the next two days. I am at a point where the more I try to study, the more my knowledge seems to get all mixed up. All I am getting now is diminishing returns for my efforts. So, I am finished with studying. I’m going to put on a movie. Come on, exams, do your worst!

Ethical Minefield

I visited an in vitro fertilization (IVF) clinic today as part of our OB/GYN rotation. I am aware of the debate around assisted fertility – Should people who are infertile for whatever reason be able to use technology to achieve pregnancy? Should the government allocate any resource for assisted fertility? Isn’t infertility natural selection in play – that people who are infertile are not meant to pass their genes to the next generation? Are we interfering with evolution by providing the means for those people to achieve pregnancy? – but with the IVF clinic visit, I came to realize a whole broadened range of ethical issues beyond the rationale behind the use of IVF.

Okay, this is an IVF clinic, the people working here and the patients probably all have looked past the ethical issues of using IVF. But IVF comes with a slew of new ethical issues. Each IVF cycle produces a number of embryos; the guideline allows only one to be implanted, so the rest of them are frozen for five years. After that, the couple needs to make a decision on what to do with them – keep them frozen for another five years or let them thaw (and die). What if a couple splits during that time? Does each parent have custody of half of the embryos? What if the father gives custody of all of the embryos to the mother? Will he still be liable for child support if the mother then decides to have a child using one of the embryos? Just when the law and guidelines are interpreted to provide a solution to a scenario, more what-ifs can come up, each one pushes the ethical and legal boundaries and contributes to the minefield that can potentially blow up in the faces of doctors and patients.

One of the doctors told us that, after working in the IVF for a while, he came to realize that everyone needs to come to terms with each ethical dilemma that may arise with every decision. On the issue of when life starts, he has come to the conclusion that life does not always start at conception. Like with natural conceptions where chromosomal abnormalities are the most common cause of first-trimester miscarriage, a good percentage of the eggs fertilized via IVF technology contain chromosomal abnormalities and thus not viable for implantation. Not all eggs and sperms are created equal and, due to de novo mutations, not all embryos are created equal. To someone who believes absolutely that life begins at conception, the number of embryos destroyed for that reason alone would make the place seem on par with abortion clinics, not to mention the thawing of all the frozen embryos. Clearly, one would have to become a moral relativist to be able to work in this field.

Brisbane Bound

Four weeks came and went in Hervey Bay. It has been busy but also very productive. I caught all four babies. The consultants and PHOs have been refreshingly nice to us and the teaching was excellent. So, I am leaving Hervey Bay feeling that the subject of obstetrics and gynecology is much more under control than four weeks ago. I don’t think I can expect clinicians in Brisbane to give me as much attention in the next four weeks.

Good bye, Hervey Bay. You have been good to me.

Oh, Baby Baby

A major requirement for this rotation is that each student has to catch four babies. My experience with catching babies runs as deep as the one time when I helped out the midwife at a birth at the beginning of last year on my rural rotation. Unlike a lot of things in my medical training so far, like taking history and doing physical examination where we practiced over and over until we were blue in the face, we are stuck straight into it when it comes to delivering babies.

But I learned. The midwives were there to coach me on delivering the babies while coaching the mothers on breathing and pushing techniques. I realized that a major part of delivering babies, from the perspective of the midwife, med student, or doctor, is like cheer-leading, sans pom poms. When the contractions during the first stage become too painful for the mother, I offer her nitrous oxide and instruct her to breathe through each contraction. When the mother is exhausted and thinks she can’t push anymore, I follow the midwife and encourage her to push – with a calm voice. As one of the midwives put it, catching the baby in itself is the easy part. A lot of the work goes into what you do for the patient before and after the birth – anything from getting drinking water for the patient to wiping her bottom after a series of hard pushing, from helping the patient get into positions that might be a bit more comfortable to getting her warm blankets, it’s all part of the job. Of course, the medical side of things like taking her obs, documenting the progress of labor, and pain management has to be attended to constantly.

At the end of the day, seeing a healthy baby cooing in the arms of the exhausted but relieved new mother would bring a smile to anyone’s face, even if it’s two in the morning.

Done Deal

I logged onto the Queensland Health website and there it is: two buttons. Accept – Decline. I slide the mouse cursor back and forth between the buttons.

Click.

Since Friday, I have been waiting to see if there is anything that tells me I should accept Queensland over New South Wales while all along, the nomad in me has been winning the argument. As far as the hospitals themselves are concerned, one is bigger than the other, but each has its advantages and disadvantages, so on that regard, it’s a wash. My gut feeling tells me to go for Wollongong. I know, it’s quite a big decision to make on gut feeling. It’s also a decision that may influence what road I go down in the future. Acting on gut feeling has served me well before; it has gotten me out of potentially sticky situations as well as steered me down the right path in the past. So once again, another major decision in my life is made.

The screen now reads “Logan Hospital: declined”.

Here I come, Wollongong.

Decision 2008

Queensland Health called me today and offered me a job for next year. It’s in a suburb between Brisbane and the Gold Coast.

Western Australia sent me an email – no deal.

South Australia: not a peep. No email, no phone call. I guess I should put them in the “No” column.

So now the choices for internship are between Logan, Queensland, and Wollongong, New South Wales.

On one shoulder, the nomad in me tells me to run with Wollongong: it’s time for a change of scenery. Brisbane is so four years ago. Go to a new and exciting place, make new friends, start a new life! Wollongong is only ninety kilometers south of Sydney, just think of all the culture you can access. The beach is within walking distance from the hospital. With all the national parks around the city, you won’t feel trapped.

On the other shoulder, the settler in me tells me: with Logan, you can live in Brisbane or the Gold Coast. The commute won’t be long either way. The move will be a piece of cake. You’ll be closer to your friends. The pay is better in Queensland. You’re already thirty-one, do you still really want to move around all the time? Is being able to fit all your worldly possession inside your car still something you want to boast about?

I think I will give the two of them some time to fight it out. I have until next Wednesday to decide on which position to take. Maybe I will have some kind of epiphany between now and then that will help me make a decision. Maybe.

A Different Demographic

On my way to the hospital in the morning, I walk past the hospital sign. As per Queensland Health regulations, smoking is forbidden past the sign. So naturally that’s where clusters of smokers congregate, with a haze of smoke wafting around them or being blown into people’s faces as they walk by. One of the people leaning on the wooden stump is a young thin woman with a bulging abdomen, obviously pregnant. And yet, she’s puffing away without a care in the world.

I normally try not to be judgmental about people’s behaviors, even when there is a direct connection between their past or current behaviors and their subsequent illnesses. As long as they know the risks and are willing to take their chances, I am of the opinion that we, as health care professionals, are not there to save people from themselves. But when a woman becomes pregnant, it’s an entirely different story. All that individual freedom to choose what to do to their own body argument goes straight out the window, because it’s not about her body anymore. I am sure she has been educated about the dangers of smoking while pregnant. By knowingly allowing these toxic substances to circulate around her body, cross the placenta, and mix with the fetal circulation, what she is doing really amounts to child abuse.

~~~~~~~~~~

At antenatal clinics in the last few days, I saw quite a few pregnant women in their late teens coming in for check-ups. Some were on their first pregnancy, but some of them were on number two or three. I was told that it’s quite normal for young women to start having babies while in their teens in this area. The youth of these young expectant mothers were only rivaled by the young mothers I saw in rural Zambia. Such is life in rural Australia. While women in metropolitan areas focus on their careers and put off child rearing for later and later, women in rural areas run on a different clock, with a completely different set of priorities. I am not saying there’s anything wrong with having children so young, but to someone who grew up and live in the career-focused paradigm, seeing people who are content to start families as the first priority in their lives at such a young age is something that will take time to get used to.

Like they say, different strokes for different folks.

Back to Hervey Bay

It’s the beginning of the second-to-last rotation: obstetrics and gynecology. I will be spending the first four weeks of the eight-week rotation back in my old haunt Hervey Bay.

The med school is putting me and another fourth year up in a house in a new subdivision just behind the hospital. Driving down the new road behind the hospital, I can’t help but notice that the neighborhood in front of me could have been airlifted straight out of Anywhere, USA, and plopped down in the middle of Australia. The same denuded landscape that had been clear cut to make way for cookie cutter houses, the same manicured lawns with feeble saplings propped up by supporting frames, the same deserted streets in which the only indication of human inhabitation are the cars parked in the driveway. The elegantly designed Queenslanders that are built and oriented to suit the warm and humid Queensland climate have given way to the cheaply and massed produced prefab homes. Another unique regional feature has died a quiet death by the forces of McDonaldization of the Western world.

This sterile neighborhood will be my home for the next four weeks.

In the morning, I walk over to Hervey Bay Hospital that had grown so familiar to me last year. Walking down the central corridor like I had countless times before, I keep running into junior and senior doctors who had taught me last year. To my surprise, they all recognize me and stop to chat. Sure, there were only ten of us here last year, so they didn’t have to deal with a thousand med students coming through day in day out. But stopping to chat with a lowly medical student? That’s way beyond what I’d expect big shot doctors would do. And yet, there I am, shooting the breeze with the head of surgery, being asked about my elective in Zambia by the consultant in medicine, listening to another surgeon recounting his OB/GYN rotation during medical school.

It’s nice to be back in Hervey Bay.