AUMSA Blog Entry 7 Specialty Medicine
This is a 6-week run comprised of two 3-week stints chosen from a selection of specialties. For me, they were cardiology and renal. I started with cardiology. This was my first run in the medical half and on the first day, I immediately noted the differences compared to the surgical half!
1. No bustling around to hunt for patient’s notes. You see all the patients in cardiology ward. Duh.
2. 0715 starts were unheard of.
3. Ward rounds will sometimes last past 1600.
In cardiology, a typical day starts in the CCU (coronary care unit) of Lakeview Cardiology Ward, a ward that is only specific to patients who require extra monitoring. The way the team works is such that each week there will be one consultant on call and they cover all the patients on the ward as well as the emergency cases. Handovers are every Monday and the consultant goes over each patient with the consultant in charge the following week. There are two registrars: one ward and one referral registrar on the team. The former is self-explanatory while the later is one who attends to all the patients who require cardiology input in all the other wards. If you have a chance to, try to follow both registrars within your timetable. Oh yes, you will also be given a timetable showing when you will be sitting in on some echocardiograms, stress echocardiograms and stress ECGs.
Be prepared to use your stethoscope and pick up murmurs, clicks and gallops. During this attachment, my ears grew accustomed to the S3 gallops of acute heart failure and ejection systolic murmurs (both pan-systolic of mitral regurgitation and the crescendo decrescendo of aortic stenosis). I had a partner for this attachment and whenever we didn’t have ward rounds or patients to interview, we would be at the cath lab. There we had a chance to see coronary angiograms +/- stent placements and pacemaker insertions. I remember the very first day we watched an angiogram being performed! We were both trying to figure out if we could identify the anatomy correctly and tried to name each vessel that showed up on imaging. We both found it a bit difficult and thought, man we need to revise our anatomy it looks nothing like what we remembered studying… turns out, the patient had a quadruple bypass in her heart of which some were occluded. On top of that, they weren’t classical bypass sites, which all the more complicated the picture! The consultant had a good chuckle when he noticed our attempts at identifying what wasn’t normal anatomy and reassured us that “no, this isn’t what you should expect!”
During the 3 weeks, ask to admit patients when they come to the ward and present them the following day. This really helps improve your case-presenting skills. Also, don’t forget to hand in a minimum of two cardiac patient cases at the end of this run together with your CSR form. I ended up presenting one of my cases during synchronous learning and the thorough detailed history really goes a long way! All in all, amidst the beautiful $8.5 million dollar lake view overlooking Lake Pupuke and cheerful, bright staff; this cardiology run was quite enjoyable.
Now, let’s talk renal. This run really surprised me in how much more integrated it is in terms of covering general medicine. The kidneys, once it deteriorates affect multiple vital organs in the body as a consequence such as the brain and heart. As such, a lot of care is taken with treatment and it is very individualised to each patient. In renal, patients are broadly separated into two groups: those under nephrology or dialysis. You will get to spend quite a lot of time in both, learning the multiple causes of kidney failure and their treatment.
Like cardiology, we were once again given a timetable, which included numerous teachings by various members of the team such as the renal dietician and the transplant nurse. It was very informative to learn how each discipline contributed to the care of a patient. From being able to feel the filtration tubules in the dialysis machine first hand (the consultant broke one dialysis filter for demonstration) to tasting Nepro (a nutrient dense drink for patients), we had really good teaching sessions during this run. It was during this run that I palpated an enlarged liver and spleen for the first time! Yes it was quite exciting… you will never forget what an enlarged liver feels like after you’ve felt it for yourself. Do you remember the routine kidney balloting, which you never quite know what you’re feeling for? Oh trust me, you will know when you are feeling enlarged kidneys.
Like cardiology, the assignments for this run include 2 case histories and a CSR form. You also need to complete a mini-CEX, which is a 10-15 minute assessment of your history taking and focussed examination skills. These runs have been thoroughly enjoyable and were made even better by the teams we were on. All in all, the pace here is generally gentler and you have more time to yourself. Two weeks of vacation and GPOPS ensue (:
AUMSA Blog Entry 6 General Surgery
Gen surg (don’t mind the lingo) is a 6 week run chockfull of appendicitis, cholecystitis, diverticulitis, pancreatitis, hernias and abscesses. Then, depending on your team, you might get the rare hydatid case, some Mirrizi’s syndrome, Fournier’s gangrene, Ivor-Lewis and/or Whipple procedure.
A typical day starts with a ward round beginning 0715 to 0730. Catch your team, hunt for the never-ever-where-it-needs-to-be notes, hunt for the nurse in charge of the patient to find said notes, FIND SAID PATIENT, open up the observation charts, be ready to flip to the fluid charts, report on quantity and type of poo and be ready with your stethoscope around your neck (it’s not necessarily for you). Repeat on each level where your team has patients. One of my consultants believes in gravity-assisted ward rounds. During his ward rounds, we begin the day climbing 8 flights of stairs. We then take the stairs down to each floor that our patients are in. If this was a post-acute ward round, we get anything between 60 to 80 patients. Exercise for the day✔
In between surgeries, there are clinics to attend. The best way to learn from clinics is to see patients on your own and then present it to your consultant/fellow/registrar. Presenting cases…ah yes, in surgery short and relevant positives are the way to go. I watched one of the consultants nod expressionlessly until he heard the word “bilirubin levels were…” for a patient presenting with cholecystitis, before he finally smiled. You’ll learn, don’t worry.
Mid-run, I started on Complications, a book written by Atul Gawande. An established American surgeon/writer, Atul describes his personal encounters in surgery and the thoughts he had from a surgeon’s perspective. The timing couldn’t be better. After the third week, I was feeling a bit run down and not entirely sure if I was learning as much as I thought I would be. After a quiet weekend with this book in hand, I was surprisingly recharged and looking back, I definitely found myself enjoying the surgical run towards the end. I definitely recommend this book. After reading this book, I was reminded of the video I encountered back in pre-clincals: https://www.ted.com/talks/brian_goldman_doctors_make_mistakes_can_we_talk_about_that. Thoughts?
Assignments for this run:
1. POGS (pocket organiser for general surgery) 40%
2. Present a CAT (critically appraised trial, refer Prof Rod Jackson’s lectures) 40%
3. Consultant Supervisor Reports (as per usual) 20%
Start POGS early, Day One is a good day to start. Try to find a context to each patient for learning purposes. Essentially, there are 19-20 core topics to cover, with an additional 3 for distinction if you’re going there. My team specialised in the upper GI so naturally, there were some presenting complaints that I didn’t get a chance to see. This will happen to you too, be it skin or colorectal, bariatric surgery or upper GI. One way around it is to ask your friends on another team to discuss that particular case.
For the CAT presentation, discuss with your team as to which topic you should look into. Most likely they would have a paper or two at the back of their minds, especially the registrars. Talk to them. For the presentation itself, take it as a chance to practice your presenting skills. This is a safe environment to learn and sharpen those skills.
The online portal for Gen Surg is also a helpful resource. Read through it before you start, it prepares you for the between-patient questions.
All in all, Gen Surg was a busy but rewarding run. Two weeks of formal learning next before the medical half commences. Lunch dates and catch-ups with those in different DHBs ensue.
AUMSA Blog Entry 5: Anaesthesiology
“Oh hello there… Sorry I didn’t notice you there, I’m still feeling a bit sore after the operation… Wait just a second, where’s my PCA?…*click*… Ahhhh all better… How am I feeling? A bit nauseas actually, and I keep feeling like I need to vomit. Is there anything I can take, doctor? Where’s my baby, doctor?”
Points for guessing where the patient is and which anaesthetic procedure she went through (;
I was in Auckland hospital for this run and thoroughly enjoyed it! I especially liked being attached to anaesthetists in different specialties each day. If you are at Auckland, you will get a chance to be on the cardiothoracic, the obs&gyn, general surgery, acutes, Starship and pain team. The basic principles are fundamentally the same but due to the nature of the operation itself, you will observe many different ways of carrying out the anaesthetic procedure. This just goes to show how versatile anaesthesiology can be, with the plus side of being able to observe some pretty intense surgeries such as open-heart surgeries. That was my first time observing a heart surgery and I have to say, that stole all my attention. My consultant was very understanding and saved our discussion for later while I stared in awe (thank you!).
Things to tick off for this assignment:
• Blue book: get each AM and PM round signed off during your 2 weeks. There should be 14 in total
• Anaesthesiology case history: details are in the orientation pack, just remember to follow through with the patient
• OSCE: last day of the attachment at Tamaki campus. Hint: don’t forget what you learnt in the first two days of teaching
• There is a test on the first day at Tamaki. Watch the 3 videos online and you’ll do just fine
I had many moments during this attachment. A baby girl was born to a mother through a Caesarean section and as soon as she was delivered, the nurse brought her around to mom and laid her over her chest for what they called ‘skin to skin’ contact. Apparently this helps the baby regulate her temperature and familiarise herself with the mother’s heartbeat. The father was on the way, the surgeons were busy dealing with the placenta and the incision while the anaesthetist was occupied monitoring mom’s stats. From where I was standing, I couldn’t help but feel so privileged to be part of the mother-daughter bonding moment. It was a truly moving experience (:
At Starship, I assisted in providing general anaesthesia for a three-year old boy with leukemia who came in for a lumbar puncture and chemotherapy. This three year old is by far one of the liveliest kids I have ever encountered. He came in with his dad and started counting the number of screens in the room (a distraction that was well set up by the dad) before lying down on the operating table. With a big proud smile, he proceeded to lift up his arm with his identification tag and prompted the nurse to look at it: signs of familiarity with the procedures in the hospital. This saddened me. This was all he knew and this was all that was normal to him. When my palm rested on his head to position it for the bag mask, I couldn’t help but notice the first signs of thinning hair. My heart ached a little.
All in all, this attachment was an enriching one. My next run will be in general surgery. I can’t believe that my surgical run is coming to an end! Time really does fly, doesn’t it? Stay tuned for GI talk in the next post, it might be a mouthful
AUMSA Blog Entry 4: General Practice
This is a two week run which usually takes place out of Auckland in places such as Waihi, Thames, New Plymouth and so on. If you are placed out of Auckland, take that chance to explore the area where you are! Some of my friends stayed at a bed and breakfast inn, spent the evenings cruising the beach and came back loving the run with endless stories to share (cue to check out airbnb). It was pretty inspiring to hear about how and why certain doctors practice the way they do and how they came about to practice where they are.
I was initially going to Thames but for numerous reasons, was relocated to Papakura (which is in Auckland, yes, but some of you will also be placed in clinics within Auckland). During this run, my consultant scheduled time for me to be at the A&E clinics, GP clinics and podiatry sessions. There were also physiotherapy, dental and X-ray clinics in the same centre, which due to time constraints I didn’t get a chance to observe. This run really showed how multidisciplinary a practice could be. I was also asked to come along to one of the CME sessions his colleague was holding at Beaufords in Totara Park (Yay, free dinner!). The session was on Uncommon Medical Emergencies, which I found very educational as what was being taught touched based with basic physiology (fresh from preclins right?).
Remember the green book from ED? Yes, that book is also used to assess your GP run. You may have had limited chances to be hands-on due to the acute nature of ED but in GP, you will have more opportunities to participate. To get the best out of your run, look at the back of your green book and try to get as many of those ticked off! Ask to help wherever possible. The nurses are always willing to teach and they are more than happy to let you clean some wounds, change some dressings and help with putting a cast on.
GP was good overall. I reckon I would have enjoyed it more had I not been so tired from the travel and feeling a tad sick towards the end of the run. Anaesthesiology next, tune in!
AUMSA Blog Entry 3: Musculoskeletal (Orthopaedics +Rheumatology)
Just to clear up some discrepancies, my post on rural general practice will be up after this one as there has been some reshuffling of my placements.
The orthopaedic run is a four-weeks run where you spend one week in Middlemore Hospital for teaching and the remaining three in hospitals (for students in the Auckland region only). The first week of teaching covers quite a portion of what you will encounter in the hospital as well as some teaching around the OSCE, which is one of the FIVE assignments you need to complete by the end of the run. The other four being:
• a critical appraised topic (CAT) on a rheumatology case,
my advice? Attend the rheumatology clinic in the first week to find an interesting case you want to investigate. Then, hunt for appropriate papers to evaluate. Once you have the paper, you can either start and complete it straight away (as did one of my colleagues) or finish up all the other assignments and complete it after the stress of OSCE. It’s a breeze once you’ve found a topic.
• case history and presentation (only for North Shore Hospital students)
once again, find your patient in the first week so that you can follow them into surgery. It just helps to have more time to find out more about the condition of your patient. In my case, it just so happened that my patient had an injury that occurs only in 0.01% of all fractures. Not much was found in literature so it served for an interesting presentation.
• completion of a checklist
print this out before you start the run and get them signed off as you go, you don’t want to panic in the last week when you are busy practising for OSCEs and realise you still have some to tick off!
• getting your clinical supervisor report (SCR) form signed off by a consultant on your team
there will be variations in the quality of assessment you get, some may not be reflective of what you put in, sometimes for the better and sometimes for the worse … from talking to my colleagues, sometimes it’s just a matter of luck, so don’t be discouraged if you don’t get what you expect. Lesson one: Know your supervisor’s personality and catch them on a good day. From observations, that does help.
Prior to starting in the hospitals, I had been forewarned and advised to brace myself for some pretty tough times. And brace myself I did, only to be received by a team that was more than happy to teach and pretty fun to be around. So, lesson two: Don’t predict your experiences based on another’s, as they are bound to be different.
There are plenty of learning opportunities in orthopaedics, be it clinics, theatres or even clinical teaching sessions. It is really up to you to pursue them. Remember, no one is going to care or wonder whether you turn up at any of them or not because a) it doesn’t affect them and b) they are too busy to be keeping tabs on you. It is entirely up to you what you want to learn and how you get about it. One of my colleagues gave me this very useful advice. It goes along the lines of:
“Come in to the hospital and have a goal you want to achieve each day. It could be as simple as ‘I want to practice getting a good history from a patient today’. If you came in each day with a goal in mind and you achieve it, you will be making progress.”
On my first day, none of my consultants were around so after the ward round, there was literally nothing I could attend. That was 10 o’ clock in the morning. Reluctant to leave without learning anything, I attended clinics with my friend’s team. While I was there, the registrar ran through a shoulder (which came out in the OSCE, why hello) and knee examination with us and explained the purpose of each part of the look, feel, move and special tests. I went home that day feeling pretty fulfilled. That pretty much set up the tone for this run.
In the next two weeks, I spent most of my time going between clinics and theatres. The best way to learn in theatres is to scrub in. Even if you’re not assisting, you can at least see what is going on and if you’re lucky, get some teaching by the surgeon too. Otherwise, you spend three (or more) hours in a theatre trying to look interested in something you can’t even see and run the risk of being told off by the nurses for standing to close to sterile equipment. No thanks! When in clinics, observe and ask. Trust me, you will learn so much when you engage in conversations with your registrar/consultant!
Towards the end of the run, I began to realise how much I would miss orthopaedics. It wasn’t just the specialty alone but also the community that came with it. A few of us from our group got together and baked some food for the last day as a sign of appreciation. Quote one of the consultants at handover “This is by far one of the best group of medical students we’ve had”. Not a bad way to end OSCE I reckon!
Right now, I am on a short break before starting anaesthetics. Attached are some pictures for your palate, Enjoy!
Emergency Medicine + Procedural skills – 1/3/2015
Three (and an optional fourth) shifts in the Emergency Department (ED) for two weeks = plenty of free time. Personally, this meant more time to study at a relaxed pace, get in my weekly dose of exercise and more time to enjoy food. Mindful eating requires time; remember that.
Starting with ED was great as you get more time to read up on case studies, notes and background of presenting complaints (PC) before and after the shift. During this run, your green book is gold. In ED, you don’t really get a team as most consultants, registrars, HOs, TIs and medical students change constantly. Bearing that in mind, you need to be independent and self-directed in your approach to learning. Present yourself at handovers. That should usually be at 0800 for the day shift and 1700 for the night shift. Introduce yourself and your position if the opportunity arises or at least make your face familiar to the team on your shift. Take note: logistics, interesting and/or important cases get discussed here so you may not have the opportunity to do so. There is usually a consultant in charge for each shift, so if you are not quite sure who you should be attached with or what you should do, discuss this with them after the handover.
Once you get started, check the dashboard/system for the list of patients and the PC. There are four main PCs you need to tick off during the ED run: acute chest pain, dyspnea, acute abdominal pain and back pain. However, don’t just keep to the bare minimum. This is a chance for you to practise taking a good history, carry out physical examinations and learn how to present your patient to the consultant in charge. In ED, you will most likely be talking to a patient who has been seen by a consultant. Take this opportunity to present the patient concisely and discuss the implications/differentials of the patient, investigations, treatments and subsequent actions/referrals. A tip from one of the consultants: “You have 5 seconds to gauge my interest, so make sure it’s good”. What he was implying was: less waffling, more facts, no monotone and be able to answer any questions about the patient. TIP 2: check the patient records before presenting; just in case you missed out on any crucial information ie on warfarin for a PC of headache. TIP 3: Eyeball numbers. The red in the investigations indicate pathology so find out what they are! Urine samples don’t turn up in red so learn how to interpret the numbers and observations.
During this run, you will also be attending two full days of Procedural Skills and a Health and Well Being Day. Get prepared for plasters, IV lines, PRs, sutures, insertion of nasogastric tubes (on each other…), staple removals, ABGs, catheterizations, ear wax and hollow tube inspections (ENT/ORL fun) and various clinically relevant procedures. Great way to refresh what you’ve learnt previously before starting the year so you actually know what you’re doing in the wards. For the later, be prepared to relax, discuss about burnouts in the medical setting, time management, death and dying and ‘how to survive in the wards’. Relevant. I promise.
T’was a great ease into the clinical setting. Rural GP in Thames next; watch this space!
AUMSA Blog Entry: Formal Learning – 18/02/15
In Medicine, we thrive to shorten our summer breaks as we progress through our degree. Arriving to Grafton a month ahead of the typical semester dates, 4th years begin the year with two weeks of Formal Learning. These two weeks are packed with 53 hours of learning. No typo there, I assure you.
As dreading and exhausting as this may sound to some, especially if you’re still on that holiday buzz, I personally think it was a great way to start the year. You finally get to catch up with your friends whom you haven’t seen the whole summer! Stories. You get an abundance of stories! From the travellers to the researchers, from the hibernators to the workaholics, trust me, second-hand experience is something you don’t want to miss out on. On the academic side of things, the content itself was mostly tying-in what we had already learned and making it more clinically relevant. Most of our lecturers were from across the road, thus turning up in scrubs, dealing with on-call cases and what not. You really get a dose of what to expect in what we call ‘the real world’ now.
Oh, did I mention we get a long weekend in the middle of it? Thank you Waitangi Day! Perfect time for a road trip for those who just returned to Auckland, I recommend it. Alternatively, you may also start on the books to prepare for your general surgery/medicine rounds, if that happens to be your first. Don’t worry if you feel like the only one nerd-ing it out, you will find that there are quite a number of us who feel just as nervous about starting as you.
We ended formal learning with Dr David Rowbotham, gastroenterologist from across the road. We arrived to class finding a lecturer who not only had no lecture slides or notes, but also had no shoes. ‘Well,’ I thought, ‘this was going to be interesting’ and I’m sure I am speaking on behalf of the class when I say, indeed it was. Sparing the nitty-gritty GI details, this special mention was for the subtle/not-so-subtle advice he had slipped in during his lecture for us 4th years, and also some memorable ones I thought was worth mentioning.
“If you arrive late, you think your time is more valuable than mine”
“If you attend anything late, your career will go downhill. Very fast.”
“If in doubt, look smart”
“Don’t answer a question with a question”
“Never look like you’re half asleep”
“Don’t say ‘like’,”
[in reference to faeces] “It may be shit to you, it’s bread and butter to me”
[in reference to prescribing] “All drugs are poison. They do good things at a price”
[in reference to guys who are planning to start a family] “In this time and age, when your wife is pregnant, you are pregnant”
All in all, these two weeks have really set the tone for the year. I don’t know about you but I’m feeling both excited and nervous to start. Signing off now to prepare for Emergency Medicine next. Watch this space!
She. Has a love for people, their stories, food, travels, and captured moments. Energises from a run and the occasional book. Is a nerd at heart. Ascribes her need to recharge despite enjoying the banter and company of people to Quiet by Susan Cain. Believes that in life “it’s the possibility of having a dream come true that makes life interesting” – The Alchemist, Paulo Coelho.
If you have a story to share about your run, send it to [email protected]. She may return in baking.
Gerald is in his fourth year, situated at Auckland City Hospital. For pre-clinical students he hopes to fill in some gaps regarding what beginning clinical years will be like, as he tries to survive the year holding on dearly to the quote “It’s okay not to know all the answers”. Outside of uni, Gerald enjoys discovering new music from neo-soul to alternative rock to beloved k-pop, and continues to search for the perfect place to eat that’s the exact combination of taste, class and under $10.
If you have a story to share about your run, send it to [email protected].
AUMSA Blog Entry: Anaesthetics
Learn all the drugs? Use all the needles? Keep everyone alive??
Anaesthesiology is a 2 week run with a very special structure: you are in a different theatre every day (maybe even every half day), following a different anaesthetist each time. This means two weeks’ worth of surgeries that may truly stun you as a fourth year, ranging from emergency cases, amputations, ENT, paediatrics, and even caesarean sections and open heart surgeries. The purpose of such a range of surgeries is for you to see how the preoperative assessments, drugs used and precautions taken differs for every surgery. When you realise how every little question and every decision made can determine whether the patient stays alive in surgery or not, it’s hard not to truly appreciate how much of a critical role anaesthesiologists play here.
This run starts off with everyone in your group from all cohorts (and the stories from the different hospitals that come with it) meeting at Tamaki campus to have some introduction sessions to anaesthesiology and learn practical skills that you will soon have the chance to carry out on real patients. Here you are given your “blue book”, which has a table with 14 rows (for 14 half days) to get signed off, as well as other fancy looking tables to keep track of how many successful attempts you’ve had at IV cannulation, bag-mask ventilation and laryngeal mask airway insertion.
Usually the anaesthetic coordinator/supervisor would allocate you to a theatre for the day, but don’t be afraid to allocate yourself somewhere instead after looking at the board:
a) You may want to go to a list with a high turnover rate, so you can practice your practical skills as much as you can – there is a mini OSCE on the last day which tests you on some of these skills so best to get in there while you can. OR
b) You may want to go into a theatre with surgeries that you know you might not be able to see again as a student.
You’ll have a unique experience, and you can still make it useful for your OSCE/other assessments: as long as you ask, anaesthesiologists are usually very willing to teach you anything, especially the essentials like airway management, which drugs and equipment to use, reading the monitors and so on.
Other than the blue book and OSCE, There are three other main assessments for this run:
– MCQ test in the morning of the first day, based on three videos you have to watch beforehand in your own time
– A case report, which will be quite different to your usual case histories in that they will be much more focussed on the anaesthetic perspective. Choosing a simple case may be better because submitting it online means you’ll be less likely to get away with over-exceeding the word limit, as we all do…
– Two CSRs. This may be difficult as you are getting the anaesthesiologist to mark you after being with them for only one day, or even half a day. I.e. charm-saturation time
You will also realise that anaesthesiologists are not only crucial when the patient is asleep, but also before and after the surgery too. Anaesthesiologists help calm down an anxious patient (not necessarily with non-drug methods…). They ensure the patient is in the right position before being put to sleep. They are responsible for making sure the patient’s vitals remain stable after the surgery. Memorable for me is the anaesthesiologist that took control when a 2 year old baby came in to theatre, not letting go of his father. Eventually he had to be forced out of his father’s arms and held down on the operating table. Everyone could see the fear that the child was experiencing, and the growing reluctance of the father. Here the anaesthesiologist gave clear roles to the team, kept comforting the child until he was no longer crying, communicated with the father all at once while at the same time monitoring the vitals and putting the child to sleep. For me it was a chaotic moment, and one that showed that there’s really no hiding the fact that a specialty is not a specialty without the “human” aspects interweaving it all.
On another note: finally, a much needed 2 week break! Will be back once I start my run after that: Procedural skills and Emergency medicine.
AUMSA Blog Entry: General Surgery
General surgery, for me, was the run that I heard the most about before I started my clinical years. I guess it’s the general idea of going into theatre and seeing operations happen before your eyes that makes students anticipate this run so much. It is a six week run so is just enough time to have a tiny glimpse of what the world is like from the general surgeon’s point of view.
After two weeks of formal learning, all those who were in the medical half entered the surgical half, and vice versa. And for many people this change was like entering a whole new realm of the clinical student life. We finally got to experience the differences of the two worlds, the most obvious ones being a) the number of surgeries, and even more obvious, b) the average time duration of ward rounds…! Despite knowing that surgical ward rounds were going to be much quicker, and having mentally prepared for this, it still took me a while to catch up with the new pace.
Again, the structure of this run differs between hospitals. For example in South Auckland, you stick with the same team for 6 weeks, while in e.g. Auckland City Hospital, you would be under one team for the first three weeks, then another for the next three weeks. Either way, you are bound to see a range of surgeries as long as you are willing.
On the first day I was very naively excited with the orientation and teaching session on “how to scrub into the theatre”. Then the next day, at the first theatre I attended and the first surgery I ever saw, I was already being asked to scrub in and assist the surgeon! This came as a shock to me and I remember feeling quite anxious as I still had absolutely no idea what I was meant to do. I was given the daunting (at the time) task of retracting the liver during a laparoscopic cholecystectomy. In the end I got told off a few times because I was too preoccupied with wow-ing at everything that I was seeing…
Along with the theatres, there were plenty of clinics to attend, tutorials to go to and patients to see. The tricky part was balancing everything for yourself in order to get all the assessments done. POGS (pocket organiser for general surgery) is one of the main assignments of the run, and unfortunately it can get as stressful as everyone makes it out to be. This is an assignment which involves seeing, then writing about 15-20 patients that must cover a list of topics, such as acute abdominal pain, upper+lower GI bleed, breast lump and chronic limb pain. Make sure you plan ahead and put aside time for these, otherwise they will creep up on you in the last couple of weeks! Otherwise they are a good way to see a range of patients and realise the different types of surgical cases out there.
Other assessments are
• CAT presentation: Practice your presentation, stick to the time limit, and study your CAT paper in enough detail to be able to answer any question that the doctors might throw at you.
• OSCE – currently formative but this may change in future years! Depending on the hospital you may or may not have prepared tutorials in preparation for this. Either way, ask your team to give you some teaching and be prepared to do some self-learning too
• CSRs – as per usual. Once you switch worlds you may find that the way CSRs are marked are different too. Hopefully you will catch on to these differences early in the run and get a good mark!
One thing I want to briefly mention is the “acute” side of general surgery. Some hospitals have acute days, meaning that every team will always be taking care of acute cases at any point. At Auckland City Hospital, there is a separate team dedicated to acute cases (pretty amazing right). I wasn’t allocated to this team, which meant that the only way I got to see acute/emergency cases were by staying for long days and weekends. It was here that I saw cases ranging from appendectomies, laparotomies to even a couple of shocking emergency cases too. Whichever hospital you’re at, I do highly recommend staying for at least one long day during this run. It makes you see yet another side to the general surgery life and I think it’s really worth experiencing at least once from a student perspective.
At this time of year you may begin to realise which half (medicine or surgery) makes you more energised, more tired (despite enjoying it), more curious and so on. It’s interesting when you find that one classmate talks about how exhausting they find surgeries, while another would talk about how theatre days are all they look forward to. Same goes with medicine; one talks about how tiring medicine runs are, while another talks about how much they enjoy them. Whether you decide to use this to start narrowing down your choices, or keep your options open, it’s a good time to look back and be aware of how you’ve been finding each run so far (#shamelessmindfulnesspromotion).
Overall, find out when your team has theatre lists and clinics each week as soon as possible, ask to scrub in as much as you can, and just as importantly, plan ahead so you make enough time for your assessments too. Next up is two weeks of anaesthetics before a holiday comes my way!
AUMSA Blog Entry: General Medicine – 10/07/15
General medicine, briefly, is usually the patient’s next “stop” after ED/admissions if they need to stay at the hospital for an indefinite period of time. This is the run where you get to a wide range of cases; pneumonia, heart failure, cellulitis and infected leg ulcers to name some of the more common ones. You can see a patient’s journey from admission to discharge, learn about how they go from ED to general medicine, and understand when they would be referred to a certain specialty, surgery, palliative care etc.
Like in all other runs, general medicine is slightly different between the hospitals. In Auckland City Hospital, teams rotate between upstairs (the general medicine inpatients) and downstairs (admissions and acute cases), whereas in e.g. Middlemore Hospital, teams would see new admissions and inpatients within the same day. Work out your hospital’s (and team’s) system as soon as you can so you can make the most out of your run. Also, out of the medical runs in 4th year, gen med is the one where you are more expected to stay with your team during long days and weekends, so be prepared! As a student, these extra hours are good for helping to admit more patients, get some additional teaching from the team and if you’re lucky, follow them into procedures and codes.
The number of assessments in this run ensures that you stay alert during the six weeks. These assessments include:
Clerking at least 10 patients and presenting them to the team during ward rounds – this is especially useful when you are admitting the patient as well, and when you receive feedback afterwards on what aspects of the history and examination you need to improve on. Overall it doesn’t take too long, and if motivated enough (although your team will probably have to be motivated along with you…) you can easily finish within the first half of the run.
Mini-cex – in most cases you are observed taking a history and examination from a patient and then asked to make a diagnosis.
Grand rounds – this is what you see in the TV shows, where a doctor presents a special case to an audience of other health professionals in a fancy atmosphere-d room or auditorium of some sort. Throughout the medicine half you get to attend this regularly, but in general medicine attendance is compulsory. Make tactful bouts of eye-contact with your doctor so they know you’re there.
Case histories each week and a CAT – This makes a good run for practising how to write case histories efficiently without taking too much time. The CAT on the other hand… you will learn how to do these during formal learning, but do give yourself a few hours the first time you do it, it can definitely be confusing initially.
Tutorials and bedside teaching sessions scattered throughout each week. Make sure you contact the right people early on.
Clinical supervised report as usual – depending on where you are, you could have the same consultant for the entire run, or have a different consultant every week. Personally I’ve had consultants, registrars and house officers all change several times although I was in the same “team” for the six weeks. In this situation you just give your CSR to the consultant you were originally allocated to, or the one you think liked you most…
Having these assessments to consider made general medicine the busiest run of the fourth year medical half for me. It is definitely the run that will help drastically improve your time-management and organisation skills!
6 weeks may seem long, but honestly they will whizz by. It’s hard to believe that the medical half is over for me now, and I’m still figuring everything out in the hospital. After two weeks of formal learning I’ll be entering the surgical half of the year, starting with general surgery. Let’s just hope I don’t end back at square one and have no idea what I’m doing again…
AUMSA Blog Entry: GPOPs – 10/07/15
In some of your PCS (professional and clinical skills) tutorials during your preclinical years, you get to practice your communication skills with actors/actresses pretending to be patients. If you enjoy that, then you are most certainly in for a splendid surprise in GPOPS. GPOPS – General Practice Observed Patient Simulation – is a one week run with an aim of helping us develop our communication skills with patients, as well as see a spectrum of all the different GP scenarios we may encounter. It is held at Tamaki campus, and all the students with the same timetable as you from across all the hospitals come together for this one. A good time to see some faces you haven’t seen for a while…
The mornings were scheduled for GP related tutorials. These sessions were always interactive, whether it was being given time to fill out a worksheet like in our high school years, or practicing different sorts of examinations on silicone models. It was also a good way to ease us into what we had to do in the afternoon…
After a relaxing lunch break, we were split into groups of either 2 or 3. We would then spend the afternoon rotating around a range of GP clinic simulations with different professional actor/actress patients. The slight twist in this? Instead of acting as medical students, we were strongly encouraged to play the role of the GP. So no more sliding our way out with “I’m not sure what those symptoms mean, but you should bring that up with the doctor”! For this week, we were the ones who had to come up with the answers.
With the rooms set up to resemble a GP clinic, the actors/actresses’ abilities to stay in character, and even the fact that we had to wear clinical clothes, it was difficult not to treat these 25 minute consultations seriously. As we took turns being the GP, we were tested on our medical knowledge, cultural competency, professionalism in difficult situations and ability to recognise the patient’s biggest concerns. Some scenarios were relatively simple, while others would have a twist to them that I swear were purposely designed to throw you off! The most memorable “consultation” I had to do was to take a sexual history from a woman, which involved having to tell her that her female partner may be cheating on her…
But at the end of the day, I was able to picture every scenario happening in a real GP setting, so I know all this practice will be put to good use in the future. It was a really good environment to find out what aspects of my communication and critical thinking skills I needed to improve on, as well as learn from the others in my group. At the end of each scenario, the actor/actress gave us constructive feedback on how they felt during the consultation, so GPOPS is also good for seeing things from the patient’s perspective too.
The best part of it is that this run is based solely on attendance and participation, so no need to worry about doing well. Overall, GPOPS is a relaxed run where at the same time you take so much home. Also, during med school, this is probably one of the few times you get to be at Tamaki, which has a café that sell kumara lattes, which you must try…
General medicine run next, will be posting again in six weeks!
AUMSA Blog Entry: Geriatrics – 04/05/15
Many of you will know how lovely the elderly can be, and this is no different in geriatrics. For this run, you spend four weeks in one of the geriatrics wards, such as the stroke, orthopaedic or rehab ward. But no matter what kind of person you are and what ward you end up in, you are bound to meet lots of patients who will bring out that very soft side in you…
I was allocated to the rehab ward, so many of the patients I saw were recovering from fractures, falls and hip joint replacement operations. What I first noticed when I went to the ward was that there were just as many physiotherapists and occupational therapists as there were nurses and doctors! This made the geriatrics ward a really good place to learn the more specific roles of the different professionals. In fact, this is a part of one of your assessments; the rehabilitation case history is your usual written case history with some additional sections, such as writing about the input of the physiotherapist, occupational therapist, social worker etc. as well as linking your case with common geriatrics terms (tip: please start this case history early. It takes much longer than you think). At Auckland City Hospital (and most likely the other hospitals too) there is even a large lounge in each geriatrics floor, where patients can have meals and watch TV together. With this in addition to the exercise classes, breakfast group meetings and other group activities, you can definitely notice the unique warmth that fills the environment.
There is a big emphasis placed on the social history, and our group even had one three hour tutorial that focussed on this. You definitely realise how long it takes to get a social history of sufficient detail. Do you burn pots when you cook? How many stairs do you have? Do you have rugs on your floors? When observing my team’s registrar take a full history from a newly admitted patient, the social history took just as long as the other aspects of the history combined. There are so many questions that you normally wouldn’t ask younger patients, and although it may take a while to remember them all, this run is the perfect place to practice this.
After the daily morning ward runs, there was always plenty to do. Firstly, be prepared to carry out lots of mental state examinations! This is mainly used as a screening tool because dementia is much more common in the elderly. For those at a hospital that use MOCAs (Montreal cognitive assessment), you will probably do enough to be able to memorise all the test’s questions and answers by the end of the run! Just a small tip: although some patients do really enjoy the test, you are likely to encounter some patients who don’t feel so good afterwards, including a number who apologise “for being so dumb” :(. So be prepared for this – ask your team early on about what to say and how to work around these situations. Doing this will be much better than encountering this situation not knowing what to do and leaving the patient feeling bad about themselves!
Throughout the four weeks there are a range of tutorials on various topics related to geriatric medicine such as falls, urinary incontinence and dementia. With just the one or two doctors and the other students in the same run as you (at Auckland City hospital this is around 10 students altogether, and less in other hospitals) in the room, these tutorials will hopefully be quite relaxed but also very interactive. Moreover, if you have geriatrics quite early in the year like me, these tutorial sessions are also a good time to get to know the students in your group.
A third bonus to this comes in for those who don’t enjoy public speaking! With student presentations being another required assessment for this run, many of these tutorials will be led by you or your peers. When it’s your turn to present, you can be assured that you will have a friendly audience (hopefully…). Also, the content will be more likely to be taught in a way that you will understand well, as long as your peer doesn’t go overboard with the information!
Along with the rehabilitation case history, student seminar and tutorial attendance, the other main assessments are the CSR (clinically supervised report, just like in every other run) and the community home visit: one of the highlights of the run. This is where you spend a day following a doctor or nurse as they visit some of the patients in their homes, communities or private hospitals. You get to see the patient in the context of their living environment and observe things yourself rather than asking about them, which provides a much more accurate idea of their situation. It’s also probably the only opportunity for you to get some nice fresh air while doing an assessment at the same time…
After an enjoyable four weeks, I am currently enjoying a one week break before going into GPOPS (General Practice Observed Patient Simulation. I’m in shock the one week is almost over already… one week goes way too fast…
AUMSA Blog Entry: Speciality Medicine – 10/04/15
Specialty medicine is a 6 week run where you focus on a particular specialty or organ system, such as cardiology, gastroenterology or neurology. In most hospitals you are randomly allocated to two different specialties, spending three weeks in each. I was allocated to infectious diseases (ID) in the first three weeks, followed by oncology.
The main assessments for this run are two CSRs (Clinical Supervisor Report– the main consultant/supervisor for each specialty fills in a feedback form about your participation in the wards, how well you interacted with patients and so on) and a mini-CEX (mini-Clinical Evaluation Exercise – in most cases the consultant will watch you take a history from a patient and do an examination on a certain system e.g. cardiorespiratory exam) at the end of the six weeks. Depending on your allocated specialties, you might also get additional assessments, such as written case histories or case presentations. Assessment-wise, this run doesn’t put too much pressure on you, which means you can really focus on seeing lots of patients and learning as much as you can about the specialty you’re in.
The fourth years of the Auckland City cohort spent the first day having an introductory session and orientation of the hospital, which involved all 60 students following a single doctor in a huge mob around the building! However this was the only day we had to get used to the environment, as we all got straight into our runs by the second day. In my case, I went to meet my ID doctor in his office, and minutes after, I was already following the team around for their ward rounds. Just like that, my three years in the clinical setting began.
For the next few weeks I continued to follow different registrars and consultants around for ward rounds, sat in at various outpatient clinics, took histories from patients and attended a range of meetings, conferences and teaching sessions. Eventually I also got the chance to help write up patient notes, as well as observe and assist with simple procedures, e.g. putting in IV lines for chemotherapy. Overall, I found that this was a good run to grasp a general idea of how the hospital operates and the kinds of responsibilities that doctors have on a day-to-day basis. As sudden as this change in “uni” life may seem, most people I’ve asked found it relatively easy to adapt to everything. I struggled a bit more than others to ease into it, but I think it’s safe to say that everyone will find their way around it all and really enjoy the process of it.
The experiences you have in this run will depend on the specialty you’re in and the doctors you’re with, so my experiences would be quite different to what another student in this run would have had. Even ID and Oncology were very different to each other: for example, I was mostly in the oncology ward for the oncology run, but because patients with infections are all across the hospital, I think I ended up going to almost every floor of the building for that run. Unfortunately the doctors weren’t too fond of the elevators, which meant lots of stair climbing for me… definitely gave me a good excuse not to exercise once I got home.
How the run is organised for students will also be quite different between the specialties. The ID run was all about self-directed learning: it was completely up to me to take the initiative and see patients by myself, participate in ward rounds and attend meetings. On the other hand, two weeks before my oncology run, I received an organised timetable which stated what to do and where to go for each day. Both systems had their own pros and cons, but in both situations, it is good to ask the doctors early on about what’s available for you to see and take part in for the next three weeks, in order for you to do as much as you can and make the most out of the run.
However, no matter what specialty you get allocated to, you are guaranteed to see a range of interesting cases and expand your knowledge (the amount you can learn in one day… amazing). In ID I got to see both ends of patient symptoms, from those that exactly matched the textbook definition of the condition, to extremely rare presentations of others. My perspectives on HIV were challenged, I realised how difficult sexual history taking can be and also learnt that unfortunately, antibiotics do not solve all the problems…
The oncology run definitely broke my assumption of it being a “depressing” specialty. The patients I saw there were no different to all the patients I saw in ID. Even the first time I saw bad news being broken to a patient was completely different to what I had expected; the patient was very accepting of the whole situation and told us that he was content with the news. But in the end, oncology did have its moments. From seeing patients going into a critical state before my eyes, to eventually encountering others passing away, there were many moments that I know I won’t forget. As this was the first time I had such experiences, I know that even the small details, such as the expressionless looks of a deteriorating patient’s family members, the alarms that went off before finding a patient had passed away, and the heavy emotions I would have heard afterwards behind the closed curtains, will stay with me for a long time.
But even with situations like these, both ID and oncology have proven to be extremely rewarding specialties. Even in a palliative setting, I could imagine how knowing that you can contribute greatly toward making sure the patient is comfortable and has the best quality of life possible, as well as hearing how grateful they are to be in your care, can leave an impact on you for a long time. I think I can definitely say specialty medicine is a run that a lot of you will really enjoy.
One thing I noticed at this time was the amount of professionalism the team displayed. It was clear that they were affected by this patient, however, they remained composed and were able to quickly move on to their next patient. This experience gave me a glimpse of how, without that level of control, it can be really easy to become emotionally exhausted. So two things to end this post:
1) Before entering the hospital, or before seeing your next patient, leave everything else behind. This was advice given to me by my SGA tutor last year. This is advice for me too, as I fall guilty of having had my mind drift off from time to time… especially after having just observed something exciting, thought-provoking, or even sad like above. It’s important to put your full focus on whatever you’re doing at the hospital; you can’t think and act competently otherwise!
2) Make sure you have good social support. It’s quite hard to see your friends when you’re all at different hospitals, different runs and following different doctors, so make sure you set aside some time to keep in contact with them (and stop yourself from going insane!)
Next for me is geriatrics! Will be posting again in four weeks.
AUMSA Blog Entry: Formal Learning – 18/02/15
Formal learning is a set of lectures and workshops that help prepare clinical students for their year at the hospital. There are usually two weeks of formal learning in the beginning of the year, and another two weeks mid-year.
The overall routine was similar to second and third year, with a timetable set up like in high school, where we had a morning tea time and lunch break every day. In between, we were crammed with knowledge from a range of aspects of the medical field. While some sessions were similar to the usual lectures we had in the past years, others were a lot more overwhelming. For example, the list of skin conditions named in the dermatology session seemed to never end, while an entire day was dedicated to the cardiovascular system. As lecturers tried to teach as much as they could about their field in their two hour timeslot, we were reminded of how much depth there can be to a single specialty. There were also sessions outside the science side of things, such as a two hour talk about what to do when we are facing mentally or emotional hardships. After getting past the ominousness of this, it was good to have been reminded of ways to cope with future obstacles we may have to face!
Despite being given the information from a range of sources on what we will be doing in the wards and the assessments we will have to get through, many of us could not yet get a good sense of what to expect for the year, simply because we knew it would be completely different to our previous med school routine. Also, maybe it was because formal learning was in the same lecture room that we were always in during second and third year, but the fact that we were all going to split up and enter the wards in a few days’ time did not quite hit me during the formal learning weeks. For these reasons I ended up feeling quite underprepared, even on the last day. Regardless, I thought formal learning was a good way to ease us into the hospitals, and the copious number of emails we received about where to go and what to do at the hospital definitely contributed to the overall anticipation felt by students.
Through this blog I aim to give pre-clinical students a better idea of what the fourth year of med school is like, while including some of my own experiences that clinical students might be able to relate to. I hope you enjoy our future posts throughout the year.