raspberrystethoscope

[raspberrystethoscope]

On examination

I remember being terribly excited when my stethoscope arrived. So excited that I even wrote a frightfully earnest blog post about it. Fool. These days I dread getting the stupid thing out of my stupid handbag.

Learning to physically examine a patient and actually glean anything useful is something that takes longer than you’d think, and this year the process of learning clinical skills has gone from something I quite enjoyed to something I actively hate. It feels like every time we have teaching on it there is a new skill I’m no good at and a new consultant to disappoint.

I blinked back copious lacrimal duct secretions as I tried and failed again and again to see the optic disc (it’s an eye thing, don’t ask) during opthalmology teaching. I nearly gave myself a coronary trying to hear a murmur in cardiology class. I questioned whether I’d had a stroke of my own as I tried to elicit reflexes in neuro.

I could see that optic cup from space, Izzy. I could drive a large minivan or perhaps a small bus into that optic cup. The council has had 17 noise complaints about that murmur. This week. I could’ve heard that murmur if I was scuba diving in Japan. Without a stethoscope, naturally. With the patient still here in this bed. That’s a reflex so brisk it could run in the Olympics. That’s a knee jerk that could win us the rugby world cup.

It’s like the emperor has some rad af clothes and the only person who can’t see them is me.

I made a really conscious choice this year not to lie about being able to see or hear things if I really couldn’t. I want to be a good, safe doctor, and the time to get confident really knowing what’s going on in a physical exam is now, when nobody is making decisions based on my shaky examination findings. And I know that is the right thing to do. But mixed results, eh.

The best teachers really come into their own when you admit you’re struggling, and I’ve had some really great teachers. I spent a month on an incredible team at a smaller hospital and learnt the most I have in pretty much the rest of medical school combined. I finally started to hear lung crackles, and picked up a murmur without prompting for the first time. I started getting a bit more confident spotting a certain elusive neck pulse in the wild. I was so pleased and so proud.

Coming back to the big hospital where there are heaps of students and people are a bit jaded by us has been a shock to the system.;.

I’m not sure if I’m the only student who has taken a while to pick these things up.  Actually, that’s a lie. I do know that I’m not the only one, because students talk to each other. But I think some of the senior doctors are really unaccustomed to students admitting that they don’t think they can see or hear what they’re meant to.

Don’t get me wrong, it’s not all bad here. The eye doctors spent ages helping me to finally see the optic disc. One of them sat patiently and talked me through it while I tried ever so awkwardly to find it on him. The ward I’m on currently is a lot of fun too - the patients are a delight to sit and chat with, and the doctors are excellent. I am learning. It all just feels a bit overshadowed by this growing worry that I’ll fail my exams, and that I’m a bit too crap for this doctoring charade. I never thought I’d say this, but I miss pre-clinical medicine.

[raspberrystethoscope]

Staying in school

Image: Hey Paul Studios ‘Mini Digestive System’

There must have been a time, I don’t remember exactly when, when I stopping saying “good” or “I’m really enjoying it” when people asked me how med school was going. I started saying “I haven’t dropped out yet,” and not really knowing for how much longer that would be true.

It felt for a while like the personal stressors outside of medical school and the blows to my self esteem inside of medical school were coming so thick and so fast that there was no way I could withstand them.

We all have stuff, eh, always will. I think in medical school many of us are often terrified to admit when we are experiencing mental distress. If we are distressed, there are two possible explanations: either we have a mental disorder, and therefore have to be afraid of not being able to practice someday, or we don’t have a mental disorder, and therefore just aren’t tough enough.

I’m not even going to touch that first explanation in this post. I don’t (to my knowledge) have a mental disorder, and mental illness is something with stigma that desperately needs addressing in our profession. But I do want to say something about being tough enough.

I’m a sensitive person, always have been, but I’ve also always been good in the workplace. I’ve worked very successfully as a personal assistant to individuals who were known as blunt and direct communicators. I knew where I stood, I knew when I made a mistake, and I liked it that way.

So it was always my expectation that after the boredom I felt in pre-clinical medicine, fourth year would be a comparative breeze. I would be engaged and interested, I would do a good job because I usually do, and the personalities wouldn’t faze me too much because they usually don’t.

I don’t think I had any way of knowing how much my buttons would be pushed by the particular system of personal feedback in medical school. I’ve since deleted the post I wrote at that time, but at the end of my surgical run I got some feedback that at the time honestly crushed me. I fell apart completely for a while, and it has taken months for me to be able to take the parts of that feedback that are actionable and process them.

It has also taken me months to be able to be kind to myself about my reaction to the feedback. I should have been tough enough for it, right?

Except, as it turns out, we don’t get to choose what our buttons are. They got programmed a long time ago by circumstances beyond our control. I’ll spare you the details of my buttons, because they are not important. But it can be helpful to understand, I think, that when someone reacts to something in a way that just seems crazy to us, probably the situation in the here and now is not really what they are reacting to.

Of course, that isn’t to say that the reaction is helpful. It also doesn’t mean that the stimulus was benign, or that some degree of reaction wasn’t justified. I have a strong will and an unshakable sense of justice, and so it has taken me a long time to accept that however unfair some things in my immediate environment feel to me, I mostly can’t change them. I can only change whether or not they break me. And I’ve decided they won’t.

Reprocessing trauma is hard work, and as yet I’m just scratching the surface. But good psychologists are worth their weight in gold, and I have every hope that with the help of mine, I can get to a place where my well-being is no longer incompatible with medical school.

I had to go back to the surgical department a couple of times this week. I hadn’t done one of my exams yet, and there was a tutorial I wanted to attend to make that easier. There was a time when, if you’d asked me, I would’ve said I couldn’t ever set foot in that department again. But I did, and it wasn’t a big deal. People recognised me and smiled. I did the exam today, and it wasn’t great. Hopefully I passed, and if I didn’t I’ll deal with that. Life goes on.

The personal stressors haven’t gone away, and for the most part I don’t know if they ever will. We all have stuff. But all the time I’m getting better at finding ways to like myself and believe in myself, even on days when it’s in spite of the feedback we get here, and not because of it.

I caught myself geeking out about medical things a few times recently in a way I wasn’t sure I could again. I caught myself loving what I was doing. If you ask me how med school is going now, I’ll say “good”. I’ll say “I’m really enjoying it.” There’s a good chance it won’t be a lie.

[raspberrystethoscope]

Down but not out as far as my love for surgery is concerned. After a few days of wallowing spectacularly, today I made small talk with a surgical registrar I saw at the local cafe like a wee trooper, and did some suture practice on an orange. It wasn’t the best material but you use what you have, fam. First one to tell me I should’ve used a banana/pork skin/chicken gets a slap.

[raspberrystethoscope]

I touched a liver and it was awesome

I first wanted to be a doctor because of Grey’s Anatomy.

That’s probably not something you’re supposed to admit when you’re a medical student. You’re supposed to have always known you wanted to be a doctor, worked towards it for as long as you can remember. You played with a toy stethoscope and plastic tendon hammer when you were still in Pull-ups and never doubted your path for a second. Or perhaps you got sick when you were young, or someone you loved got sick, and you watched the doctors working and decided you wanted to be just like them.

By the time you arrive at university to try for entry to medicine, you’ve been working towards it for years. You’ve taken the right subjects at school. Maybe you took UMAT in high school for practice. Maybe your parents are doctors, or know doctors, and you shadowed them, watched them in surgery, sutured pig trotters for practice at the kitchen table. Your education is a straight, bright line from primary school to specialty training.

I sometimes envy the minority of my class for whom this “ideal scenario” was true. I didn’t even think about being a doctor when I was at school. I didn’t take the right subjects: instead of biology I took drama, after getting kicked out of chemistry (oops) I took economics, and when school and teenage life was getting me down, I took off to live with a boy.

It was in those pre-Netflix days that I first got the box set of Grey’s Anatomy out on DVD. I was hooked from the first episode. It was like the inspiration I’d been missing had finally materialised.

I can give a thousand other rationalisations for why I came to medical school, and all of them are true in their own way. But the greater truth is that for some reason, as an 18 year old watching that show, I knew, deep down in my puku, that it was going to be my path. And even though I gave up on it for years, that feeling never really went away.

You can’t even imagine my joy when my first rotation of clinical medicine turned out to be surgery. Now, I know what you’re thinking: “um, Izzy… I don’t think real life surgery is much like Grey’s Anatomy?”

You’re right, of course. It’s better.

Nothing I have felt in my life before came close to comparing with the elation of watching a surgeon save someone’s life with their hands. I have never experienced glee quite like touching a liver in a real life human for the first time. And my moderate competence during my second attempt at holding the camera for a laparoscopic appendicectomy (after an embarrassing first attempt - but don’t worry, no patients were harmed in the making of this blog post) was probably my proudest educational achievement to date.

It’s not all fun and liver-touching, of course. For someone as self-doubting and desperate for approval as I am, the surgical rotation can be a confronting experience. The surgeons we work with are great clinicians and excellent teachers, but they don’t suffer fools, and for now, most of the time I’m a fool. As someone whose self esteem is usually derived from feeling useful and competent, I have a lot of work to do before I’m entirely comfortable always being the least useful person in the room.

I’m a little in awe of the consultants (that’s like an attending, for those more familiar with American medical dramas than UK/NZ hospital hierarchies) and so most of the time when I’m around them I am just trying desperately hard not to say anything that reveals my startling degree of stupidity. The registrars (residents) are more approachable, and I follow them around relentlessly (but have so far succeeded in not following anyone into the bathroom).

My favourite place in the whole hospital (nay, world) right now is ED, where I can genuinely be useful to my reg by helping with meeting, examining and admitting new acute surgical patients. I hang out there whenever I can, and accidentally stayed there until 3am one night because my team was busy and I was having the time of my life.

There’s this scene in the first episode of Grey’s Anatomy where Meredith has just come out of her first surgery in her first shift as an intern, and she say to Derek “that was such a high. I don’t know why anybody does drugs!”

And that’s exactly how it feels. I’m high on surgery. I don’t know for sure what I want to be when I grow up - ED and surgery are both calling out to me and there are so many kinds of medicine that I haven’t yet tried. But I love what I’m doing so much and I’m truly the happiest and the most interested that I’ve ever been. That’s enough for now.

[raspberrystethoscope]

I read your "being a fat medical student" post and I just wanted to thank you <3 that honestly made me so happy to read. Maybe someday that won't be something I'll have to worry about when going to the doctor.

Thank you <3 <3 <3

[raspberrystethoscope]

I'm a radiology tech in a Greek hospital hoping to be a doctor in a couple of years and I just wanted to say that your post about obese docs and patients really hit home for me (I used to be fat) the enormous anxiety,the hundreds of times that I felt a burden.I truly believe that you will be an excellent doc because you know what? I can't even begin to tell you how many times I took a great ct/x ray of a fat pt (and how many times they thanked me) just because i've been in their shoes

Thanks so much! <3 (and sorry this is so late, I just figured out these asks/messages were here #techsavvy #millennial) 

[raspberrystethoscope]

Halfway

When I got accepted to med school and started this blog, I wrote about my crush on the idea of being a med student. I wrote about lecturers with white hair and kind eyes, about late night study groups and blueberry muffins and walking home thinking clever thoughts under the stars.

“I’m not unprepared for how hard it’s going to be,” I said, “although I’m sure I’ll look back and think I was.” A safe prediction I won’t give my past self too much credit for.

It has been hard, in ways I anticipated as well as ways I didn’t. Sure, the work is hard, and I spent my first semester feeling totally overwhelmed and crying in pathology tutorials (sorry Nada). But exams came and went and I did okay, and now three years into a science-based degree I am becoming less and less convincing when I shrug and say “I have a BA, I don’t know science.”

The hardest thing about this place isn’t the lectures, labs and exams (as gruelling as the latter have been). I think the hardest thing is time. Doing a six year degree, the months and years seem to stretch out ahead with the goal never quite in reach. By the time I am a doctor I will have spent nearly all of my twenties as a student.

It’s strange being 26 and at uni, not quite old enough or married enough to be a real mature student, not quite young enough or ‘spirited’ enough to want the full undergrad experience. I am incredibly blessed to call many of my classmates friends (as well as some brilliant people I’ve met here outside of school), and I don’t want to sound ungrateful. I am happy here. I guess it can just be a bit lonely when you’re in a life stage that doesn’t quite fit.

I don’t know if, by the time I graduate, I will have done the things I always thought my twenties were for: meeting someone, buying a house, starting a family. If being here and becoming a doctor means my timing is off for all those proper adult things, I can live with that. At halfway, I know for sure I’d rather be here.

Next year the class of 2020 starts clinical med school in various parts of the country, and a whole new part of this adventure begins. I’m nervous and excited to learn from doctors and help care for patients. I’m really quite sad that many of my amazing colleagues will be gone from Dunedin in a couple of days, some of them coming back only for graduation. It’s hard to understand how two years that have dragged on so long at times have also gone by so fast.

And what of my crush on preclinical medicine? For all the challenges, I think it lived up to my daydreams as well reality ever lives up to fantasy. Some lecturers did have white hair and kind eyes, I spent many nights in the library, and often walked home under the stars.

There never were any blueberry muffins, though.

P.S. I know I haven’t posted in ages. The truth is, since the (lovely) response to *that post* I’ve been slightly intimidated at the prospect of writing again (how could I top that, eh). But this blog was a record of my journey through medical school before it was anything else, and I’d like to keep that going!  Next time I’ll try not to leave it six months.

[raspberrystethoscope]

On being a fat medical student, at the start of our metabolism module

We’re starting our “metabolism” module at med school this week, and I’m dreading it with every fibre of my being. You see, I am going to be a doctor, and I am fat.

I’m not the type of fat you feel after you’ve had a big lunch, and your usually flat belly is protesting against the waistband of your jeans. I’m the real kind. My BMI hovers a couple of points below “morbidly obese”.

I worry a lot about what people will think of me as a fat doctor. For the smartarses among you, of course I’ve tried to be non-fat, it goes without saying. The thing is though, bodies don’t really like weighing less all of a sudden and are pretty good at reversing things in the long run. Mostly my body settles back to the same size 18 shape eventually.

I am always aware of my fatness, but perhaps more so here at medical school. We are training to work with bodies, and mine is a type of body we warn our patients not to have. It is the first thing described in every list of ‘modifiable risk factors’. A colleague suggests “just don’t let yourself get too fat” as we talk about preventing a certain type of cancer. A final exam question asks us to list four poor health outcomes associated with obesity. I sit through lectures with slides that have sniggering titles like “how BIG is the problem?”

Every week we learn physical examination skills by taking turns at being the patient, assessing body parts in various states of undress. I am usually the only fat person in the room.

On good days I’m relieved that the classmates who practise on me will have had the opportunity to examine diverse bodies. On bad days I feel like a huge inconvenience. These physical exams are hard enough already. We are third years and can’t do much of anything yet. We say “oh yes, I feel it” even when we can’t. We hope to feign confidence, if not competence; more often than not, we manage neither.

Fat bodies are hard to examine. It’s harder to palpate for a bony structure when it is obscured by a thicker layer of fatty tissue. Harder to count rib spaces to tentatively place a stethoscope above a mitral valve. Harder to feel the border of a liver slide over our index finger. “I hope I don’t get a really obese patient,” a colleague tells me with a chuckle.

In a couple of weeks, the clinical skill we will be learning is weighing someone, measuring their waist and telling them they should be smaller. I am looking forward to this like a root canal.

When you talk to a fat patient about their weight, it is not the first time they have thought about  it. It probably isn’t even the first time that day. I have been fat all my life to a greater or lesser extent and I don’t believe there has been a day when I have not been aware of it.  I dread eating in public and squeezing into the backseat of full cars. I plead claustrophobia and refuse to get into elevators when they are anywhere close to capacity. I always know when I am the fattest person in the room.

Fat patients know that we are fat and we know what doctors think of us. Earlier this month at the rural health conference there was a keynote by Dr Robyn Toomath, author of Fat Science. Dr Toomath noted to the audience (with half an apology) that health professionals as a group are especially prone to weight bias. This was so validating of my experience that I could have cried.

I once went to my GP with anxiety so bad it felt like I was dying. In between writing the prescription, the doctor helpfully suggested my mental health might be better if I lost weight because then I would feel better about myself. He went on to suggest that otherwise I might not be alive in 10 years. I was 22 and otherwise in good health. I went to him with acute anxiety, and he told me I would die in 10 years.

“Do you think you’re a bit depressed cos you’ve got low self esteem cos you’re fat?” a doctor asked a friend of mine when she sought help for her own mental health. Another friend managed his mental illness alone for nearly two decades because he was worried a doctor would make it about his weight. When he did go to the doctor, she told him to lose weight.

A woman I know had an obstetrician assume a gestational diabetes test result was a false negative and insist she retake the test. Another had a tumour in her knee joint that was missed for some time because her doctor assumed the pain in her knee was because of her weight.

Bludgeoning fat people with a suggestion we should be less fat every time you see us actually doesn’t make us less fat, and there is evidence that our current approach to fat patients might not be that helpful for health (here is a link to an article an excellent colleague shared with my class that I think is worth a read). It also makes us avoid going to see a doctor when we need one. But most importantly, it makes us feel like crap, and contributes to the already crushing stigma we experience living in our bodies every day.

I don’t think my friends are trying to make me feel bad when they talk with disgust about obese people. I don’t think you would find a medical student in my class who thinks it’s okay to treat fat patients with anything other than respect. But we are all passing through a medical education system and into a medical workforce that churns out doctors who make many of their fat patients feel like crap, within a health system that is failing to ‘cure’ fatness (even though doctors are giving what we are about to learn is the ‘right’ advice to every fat person who walks through the door).

And I don’t know how to even begin to fix it. But to those reading this who are health students or professionals, I’m starting by asking you to see me. See that your fat joke hurts me, even if I laugh along. See that I am reading ahead in clinical skills and wondering if I should call in sick on BMI day. See the courage it took to expose my belly for a group of slim people to perform an abdo exam.

And to those reading this who are fat patients, I want you to know that I see you. I see the times your heart sank as the new GP asked you to jump on the scales. I see the aches and pains you’ve put off getting treatment for because you know just what the doctor will say, and I’m so sorry. Medicine is not always a kind, compassionate profession when it comes to interfacing with people whose bodies look like yours and mine. But there are many wonderful doctors, nurses and students I’ve encountered since starting medical school who are trying to change that. Kia kaha.

P.s. When I was writing this blog post I tweeted about what I was writing. The replies are full of moving and horrifying stories from people who have been let down by their doctors, and clever thoughts on how to fix it from people cleverer than I. Thank you to everyone who shared their thoughts. 

[raspberrystethoscope]

How to study for ELM2

Med is different from any study I’ve done before and it was really hard to know what to study. Part of your job for the first part of second year medicine is to figure out what methods of study work for you. This isn’t the ‘right way’, it’s just my “cookie recipe” - by which I mean, cookies are awesome pretty much any way you make them, but this is how I do it.

I did not make these delicious looking cookies.

Basic principles

Go broad at first - have a basic idea of everything instead of diving down into the details of one thing at the expense of everything else

Try to see what you’re learning not so much as a science paper but as preparation for clinical learning in 4th and 5th year (and beyond).

When it comes to exams you’ll be doing things in case format, so it makes sense to keep your notes like that, at least in part.

Don’t try to memorise every detail on every slide. Focus on the lecture and module objectives!

Use the resources that your classmates link to on your page. There’s some awesome stuff floating around from past and current med students.

Anatomy give some great lab checklists - focus on being able to identify and understand things included in those checklists

Look at the appendices of your MSK lab book (when you get it) - they are gold!

Netters cards are pretty helpful for OSPE. So are the wrap up slides from Path - use them to test that you can identify the structures and pathologies involved.

Organising your notes

For every disease or pathology you learn about, you’ll be getting information from multiple different ‘subject’ areas at a time. Make yourself combined factsheets with everything you’ve been taught about a topic. An example of one I am making about meningitis is here - please note, it’s not finished (coz I’m crap) but will give you an idea about what I mean! If you use Google docs you can link between lecture notes and summary sheets within documents - I’m doing that a lot more this year.

On top of the disease summary sheets, I have block module documents (I just use Google docs) combining anatomy, physiology and clinical (radiology etc) notes. I pick out especially clinically relevant details and put them in a short “clinical summary” section at the top.

Pathology notes and disease-specific Micro notes go into the disease summary sheets mostly (with any ‘general’ non disease specific stuff in a combined pathology principles document. Other vertical modules, where lectures often relate to the block content happening at the time, I keep in separate documents so I can easily save them in multiple folders in my Google Drive to ensure they are available both when I am looking for notes about the block module and when I am looking for all the vertical module lectures.

Don’t neglect the information provided in your Micro labs, especially about procedures you performed in the lab. Know why you did them, what they told you, and include them on your disease summary sheets for the relevant conditions.

Pathology and Cases

I think Pathology is the most useful class in med, because it brings together content from all the other classes in a way that feels more clinically relevant. Do yourself a favour and take the time to fully prepare for it - don’t just skim read the slides half an hour before your tutorial, really spend some time understanding them. I do this by preparing what I can of my disease summaries in advance (and adding to them later using the wrap up slides).

Cases is similarly useful in synthesising information from other classes, but it’s tricky because they also throw an overwhelming amount of new readings etc at you. Don’t get too hung up about those - do them, but focus on how they relate to the tutorial questions in your case book.

Know your bugs and drugs

You are expected to be able to identify an organism based on gram stain and morphology (they might show you pictures for this), and any other organism-specific tests you perform in Micro labs. You won’t be examined on physically performing the tests but you need to know what they mean. Once you’ve identified an organism you also need to know how you would treat it. Make yourself flashcards for everything you know about the common bacteria - especially those in the appendices of your Micro lab book.

Know the antibiotics, and know their classes. Hit up a third year for a copy of the “bugs and drugs” cheat sheet to make a start on memorising the antibiotics, although since I believe one f your lecturers is new you might like to ask them if they think the sheet still covers the main things you need to know. Also, don’t just ignore the lists of most common causative organisms in different age groups/demographics - these are likely to come up in exams.

Smash that OSCE

OSCE forms a big part of your final grade so it makes sense to dedicate a fair bit of time to studying for it. Go into your Clinical Skills tutorials every week having read the tutorial and already attempted the skills on a willing classmate or flatmate. I also make flashcards out of the clinical information in the Clinical Skills book (theory questions in your OSCEs could cover this info, plus I imagine I’ll probably need it in 4th and 5th).

Practice under time pressure and with the pressure of a “fishbowl” or an audience from very early on so that it’s not a shock when you have the time pressure and observers in the exam.

My best advice to prepare for OSCE itself is to form a small group (4 or so people) to practice together.Start this early. To practice for the interviews, each write one or two patient scripts/scenarios and get some willing friends/siblings/hall of residence friends/friendly third years to be your actors for a practice session in exchange for chocolate etc.

This is the final in a series of posts on surviving second year medicine. You can get links to the whole series here.

[raspberrystethoscope]

I wrote a thing!

I wrote about my experiences of dissecting as part of our medical curriculum over at Corpus, an Otago medical humanities blog. I’d love for you to read it! 

http://corpus.nz/our-cadaver-is-male/

[raspberrystethoscope]

What to expect from ELM2

So buckle up because this post is going to be pure unadulterated nerdiness that I won’t even attempt to mask behind memes (much).

This post is about wtf ELM2 is all about, which to be honest is half the battle of actually passing ELM2. It’s long, it’s boring, and it’s all stuff I wish I’d had a better handle on before I got started.

The general vibe

You’ve just finished at least a year (maybe three years or more) of studying several papers a semester. You’ve had terms tests, and maybe lab reports and assignments, with an exam at the end. In medicine, there’s one paper every year, which lasts the full year, and nothing counts towards your final grade until October.

Until now you’ve had to maintain grades in the 80s and 90s at all times, and spent hours and hours awake worrying that you’ll miss out on that A+ you need to keep your GPA high enough to be competitive. Now the scale you’re marked against goes from 1 (clear fail) to 5 (potential distinction), and 3 is a (bare) pass. “Threes get MB ChBs” is your new “Cs get degrees”.

That said, I found the year pretty hard academically. It’s not that the content is that much more difficult than health sci, but there’s a lot of it. Whereas in health sci it’s usually pretty obvious what you need to know (literally everything), in med it can be more challenging to know what is expected and how you should organise your notes and your time.

Just when you’ve gotten used to (and oh so fond of) Blackboard, you’ll be thrust into the Moodle learning environment. Moodle is actually wonderful but it takes a while to find your way around.

Modules

Block modules are essentially body systems. When you are working through a particular system, most content you learn will relate to that system (sometimes indirectly). In ELM2 you do:

* Psychological medicine - lecture objectives and note summaries done by the lecturers are helpful

* Musculoskeletal (MSK) - mostly anatomy (including weekly labs and four dissection sessions), with a smattering of physiology. Use the weekly lab tests as incentive to keep on top of it.

* Cardiovascular (CVS) - my favourite block module because hearts are rad. A bit of anatomy with a lot of physiology (which is made fun by Matt Bevin aka Matty B). A big module for Pathology.

* Respiratory - fair bit of anatomy, heaps of physiology. Microbiology is important in this module as it touches cystic fibrosis, tuberculosis and asthma among other things.

* Gastrointestinal (GI) - reasonably straightforward module to round off the year. The anatomy is more complicated than I expected because you get a lot more detail than in HUBS.

Vertical modules are courses that carry over between all years of your degree. By far the most substantial in terms of content and time spent are:

* Pathology - weekly tutorials for a large part of the year

* Infection and Immunity - lectures supplemented by occasional labs

* Pharmacology - lectures and very, very occasionally supplemented with tutorials and labs (but really you’re on your own).

* Blood and Genetics are both very content heavy courses too, and you get a late start to Cancer but it gets pretty important towards the end of the year.

* Evidence Based Practice (epidemiology, basically) and Public Health are both pretty important but aren’t too content heavy (more skills-based).

Programmes

You also have three programmes for which you’ll do two hour tutorials most weeks of the year. They are Clinical Skills, Cases and Early Professional Experience (EPE).

Clinical Skills is assessed in your OSCE (worth ~ half of your final grade) while Cases and EPE type questions form part of your written examinations. EPE also has a clinical placement in a rest home.

Formative assessment

You’ll have a file in your ELM2 Home page called ELM2 Programme and Assessment Dates or something like that. Down the bottom it gives you a list of terms requirements and dates - take a note of these in your diary.

There are a few formative tests and assignments that come up during the year. Everyone freaks out about them way more than is necessary and you probably will too. The major ones are:

* ResearchSmart - online modules teaching you to do research, pretty quick to complete so get them out of the way when they open.

* Retained Knowledge Test - two of these per year for the duration of med school, to see how much you know and remember. It doesn’t form part of your assessment for your med papers so don’t stress about it, just get it done.

* Integrated Cases Formative SAQ tests - two of these, one each semester. Like a terms test but doesn’t count towards your final grade. Use them to get used to the way medicine examinations are structured, and as an incentive to stay up to date on your block modules, pathology material and Cases IDL tasks.

* Formative OSPE - OSPE (observed, structured practical exam) is a special hell that examines your grasp of Anatomy, Pathology and Histology by making you walk around a lab answering questions about specimens while weeping copiously (just me?). The formative exam is pretty much all musculoskeletal. Lab objectives and study checklists in your MSK lab book are very helpful.

* Formative OSCE - a practice consultation and your first experience of the Clinical Examination environment. You will probably run out of time. Practice lots of timed interviews in the lead up, 7 minutes doesn’t feel like a long time (that’s what she said).

* Genetics essay - a short, structured assignment outlining the relevant genetics of a monogenic disorder and reviewing a recent research paper into the disease. The structure of the assignment is pretty much handed to you so the only work is to look into the disease and find a paper you can write about. Don’t spend too much time on it, just do enough to put together a reasonable quality essay. I did it in an evening and did fine.

* EPE reflective essay - an essay about your rest home placement experiences and your journey in medicine. This is a cakewalk (and genuinely fun) for anybody who is reasonably self-reflective and can string a sentence together. If that’s not you, make a friend who can write well and will take a look at your work before you submit.

Final exams

Med exams are pretty daunting but my class all worried way more than was probably warranted in the end. (Still bitter about that Alzheimer’s question though). 

People talk about focusing on “A and three Ps” when studying (Anatomy, Physiology, Pharmacology and Pathology) but I think Microbiology (Infection & Immunity) is also super important, including the lab procedures.

Basic structure is:

* OSCE (4 x 7 minute stations, 2 are clinical interviews, 2 physical exams. If you clearly pass at this point you’re done, but if not they’ll call you back to do 4 more stations a few days later)

* OSPE (50 x 1 minute stations, 2 questions per station, mix of anatomy, histology and path)

* Writtens x3 (3 hours each, can cover any and all content taught during the year but if you look at past papers you can get a feel for what tends to come up)

If you don’t manage to pass your final exams you can be offered specials so it won’t be the end of the world! But you probably will pass, because you’re smart and motivated and got into med to begin with :)

Got a burning question that hasn’t been answered here? OUMSA will likely run “what I wish I knew in ELM2” talks with some third years a week or two into semester. Your education officer could also be a big help if you have specific curriculum questions. Or you can slide into my DMs/Facebook me/Tweet me/etc if you so choose.

This post is part in a series on surviving second year medicine. The list of posts (updated as new content is put up) is available here.

[raspberrystethoscope]

What to buy for second year med

One of the things I most wanted to know when I was starting med school was what I needed to buy. I kind of wanted to own All The Medical Things because that would somehow make it more real.

But if you’re like me and most students and have “budgetary constraints” - let me start by saying there is very little that you absolutely NEED to buy before you arrive at med school.

The essentials are…

Lab coat

For Anatomy and Histology labs you’ll need a clean, long sleeved white lab coat within the first month or so (if you don’t have one from health sci or your first degree, you can buy one from the uni but they’re around $40 - look online for better deals or second hand ones if that’s not manageable).

Women with long hair, it’s a good idea to keep a little purse/pencil case/ziploc bag in the breast pocket of your lab coat, where you can put a stash of hair ties, bobby pins and your plastic ID card holder. I am terrible at remembering a hair tie and constantly had to ask demonstrators for one, so I definitely plan to do so this year!

Basic stationery

You’ll need ordinary things like pens (although they give you a lot in O Week) paper, access to your preferred note-taking method, and a scientific calculator.

The not-so-essentials are...

While you could totally get away with only buying the lab coat before arriving, I found buying med-related things was exciting, and made me feel like I was actually going to be a real med student. Here are the things you might like to get for second year.

Stethoscope

Even though you could totally get away without a stethoscope of your own, they are very useful in the cardiovascular, respiratory and gastrointestinal modules. Plus, there’s something kinda symbolic about it eh? (I wrote more about this here).

There are lots of posts online about which ones to pick. Mine is a Littmann Classic III and my Dad and grandparents got it for me from Medisave. I chose it coz 1) people online reckoned it was alright 2) I’m not great at looking after my things so figured best not to get a super expensive one and 3) it’s freaking raspberry. So pretty. Medisave does engraving for free, but if you get the OUMSA steth you can get in on a bulk engraving order they put in later on.

Aneroid sphygmomanometer

To practice taking blood pressures. Can buy through OUMSA or hit up MediSave. Don’t go too cheap or the cuff’s velcro will be crap.

Clinical skills bag

Not essential, but I found it useful to have a single bag to keep my clinical skills book, steth and sphyg in. I just bought a super cute new one from Totes Amaze run by an Otago student (who happens to be my sister’s rad flatmate). I keep hand sanitiser, tissues and mints/gum in my clinical bag too.

Giant uni bag

You are likely going to be carrying a laptop, lab coat, several lab books, lunch, pencilcase, water, wallet and more. Your bag needs to be big enough to accommodate all of this and ergonomic enough not to give you aches and pains. I’m obsessed with my Rains msn backpack (it’s waterproof!)

Paper filing system

You get given a lot of paper handouts, some of which aren’t available on Moodle (although most are). It’s a good idea to have a method of holding onto and protecting these in your uni bag, and a method for filing and storing them at home. Kmart does a good document folder with compartments/tabs so you can separate out different subjects. I’m personally using a smallish A4 ring-binder with dividers, and sellotaping an L-shaped folder inside for loose bits of paper without holes punched in them.

Flashcard system

You need to have a system for making and retaining flashcards. A lot of people use Anki, which is great if you like electronic cards. Old fashioned Collins pre-lined index cards work well for me, using a stripe of highlighter to colour code them (could use a sticker or something, I just find this easy). You’ll likely want to keep hold of your flashcards until 5th year exams, so making decent ones consistently throughout medical school is a good idea!

Textbooks

See what you can get hold of for free on a USB - there are PDFs of most major texts floating around. I’d also suggest waiting for a while and just using library copies until you get a feel for which texts work well for you when you’re actually studying.

I personally am not a fan of learning from textbooks and have managed to make it through this year only referring to books a handful of times - so absolutely don’t feel that having a huge library of books is compulsory, unless you really want to.

If you absolutely insist on buying textbooks before you arrive, make sure you check out OUMSA pre-loved textbooks, Second Hand Books Otago etc for good deals! 

These are the ones I’d bother with:

Gray’s Anatomy for Students (latest edn) - not my favourite anatomy text, but heavily referenced in labs so would make anatomy lab prep easier

Netter’s or Gray’s anatomy flashcards - bit spendy but good for OSPE prep

Robbin’s Basic Pathology -  but you can read this for free via ClinicalKey!

Bonus pretty one: Gilroy’s Atlas of Anatomy - my fave Anatomy lecturer recommends this one and truly it’s utterly gorgeous. One of the prettiest anatomy atlases out there.

Just for fun

I’m sure I’m not the only meddie who is a bit of a geek for med-themed stuff.

Why not get an anatomical heart cookie cutter?

Or a medical school survival spoon for your bestie (or yourself)?

Or a med school problems mug?

Now I’m really just using this as an excuse to shop for cute med things on Etsy, I must be stopped! Happy shopping.

This post is part in a series on surviving second year medicine. The list of posts (updated as new content is put up) is available here.

[raspberrystethoscope]

The path to being a doctor

I don’t come from a medical family - my parents both trained as lawyers, the first generation in each of their families to go to university. None of the family friends I knew growing up were in health (save for a great uncle’s wife who is a nurse).

If you don’t have people to talk to who have been there, it can be pretty tricky to understand what is actually involved to get from the Dean’s “welcome to medical school” lecture on day one, that walk across the stage in a funny hat five years later, to being a consultant in your chosen specialty several years after that.

I’m going to do my best to give a brief outline!

MB ChB

The medical degree is MB ChB or Bachelor of Medicine, Bachelor of Surgery. It’s an undergraduate programme that takes six years including Health Sciences First Year (HSFY). Everything I’ve written in here describes the Otago degree. Auckland structures things quite differently.

ELM (Years 2-3)

Early Learning in Medicine (ELM) is the name for Otago’s preclinical programme, the second and third years of your medical degree. Even if you didn’t have to complete HSFY, you are still referred to as being in second year medicine during ELM2. When saying it out loud, students call it “E-L-M” and not “elm” like the tree. Midway through ELM3 you’ll let the medical school know your preference for which campus you want to attend for ALM training.

ALM (Years 4-6)

Advanced Learning in Medicine (ALM) are the clinical years of your degree, years 4 and 5. For these years, the class is split between Wellington, Christchurch and Dunedin. Much of the learning takes place in a clinical context at the hospital from which you’re based. For fifth year you can apply to join the Rural Medical Immersion Programme, training at a rural base hospital instead of your usual tertiary facility.

TI (Year 6)

Your sixth year is referred to as your “Trainee Intern” or “TI” year and you spend most of it working in a hospital. As part of this, you get to do an elective placement (most people go overseas). This is the first year you get paid (a little bit). It’s also the first year you’ll formally become a teacher (to younger medical students) as well as still being a student yourself. You’ll graduate at the end of this year, at which point you’ll get called a doctor.

House Officer (PGY1 and PGY2)

After graduation, you’ll complete two years of further on the job training as a House Officer (sometimes called an intern, especially overseas). People in medicine often refer to “PGY(n)” for “Postgraduate Year (n)” - which year you’re up to as a qualified doctor. Completion of this two year internship is required in order to get general registration with the Medical Council.

Registrar (PGY3+)

After finishing your House Officer years you’ll be eligible to apply for a specialty training programme. There’s a list of the specialties here. https://www.mcnz.org.nz/get-registered/scopes-of-practice/vocational-registration/types-of-vocational-scope/. The requirements for this will depend on the programme you decide to pursue. General practitioner training takes three years of specialty training (finishing in PGY5 at the earliest, while some programmes take as many as 6 (meaning you’ll finish in PGY8 at the earliest). A lot of training programmes will require you to move to a different town or city every year or so during this time.

It’s a good idea to have a look at the application process for any programmes you’re interested in while you’re still in medical school. These can be found on the websites for the College that runs the training programme. When you apply, they’ll generally take into account a variety of things to score your CV - these might include published research, previous higher degrees, skills training courses you’ve completed and time spent on rotation in your specialty of interest.

(It’s also totally fine to have no idea what you want to specialise in when you’re in medical school. I don’t know either).

Consultant

The New Zealand equivalent of an “Attending” which you might have heard on American television. You’ll be eligible to apply for this job after finishing specialty training, although my understanding is that some people go overseas to do further ‘fellowship’ type training beforehand - but don’t quote me on that!

Hopefully that gives a general overview of the path you might follow to become a grown up doctor, but I’m still a baby meddie myself so let me know if something needs correcting! 

This post is part in a series on surviving second year medicine. The list of posts (updated as new content is put up) is available here.

[raspberrystethoscope]

Top tips for life at medical school

So you’re heading into second year medicine and don’t know what to expect? A year in, here are my top tips.

You are there to make friends

Being at medical school is wonderful. In a lot of ways it really does feel like you’ve joined a profession and become part of something. Most people coming into medicine will have spent between one and three years competing for the best possible grades, and it’s a huge breath of fresh air to finally stop competing and be on the same team.

People share their notes, give each other study tips and advice, and generally support each other really well in my experience. People from higher year groups are incredibly generous with mentoring and advice.

Do your best to get into that spirit early. The people you meet in medical school will become a support system, probably your major source of social contact, and eventually your co-workers and best friends. Be nice to everyone.

A little while into the semester, OUMSA will organise peer mentoring. Join it and use it to your advantage. It was so valuable for me having someone to talk to who had a bit more perspective on med, and could talk me out of being so overwhelmed.

Get into that med school life...

My biggest regret this year was not getting more involved in medical school life at the start of the year. I’m pretty shy and anxious about meeting new people and didn’t push myself to sign up for things. It wasn’t really until partway through second semester that I actually got involved, and it made my med experience so much better once I did.

There’s so much cool stuff going on in the med school. Join a med club. Apply for conferences. Write for Enema (I hear the editor’s a babe). Run for education rep. Come to ECCO conference. Try out for med revue. Do Teddy Bear Hospital. Go to the awesome OUMSA steins and events. Whatever floats your boat, find some way to be involved. It’s a good way to get to know your class better and generally makes the year a lot more fun.

… but have a life outside of med school!

You’ve worked so hard to be on this path and it’s finally time to pursue things outside of study that build you up. Actively cultivate a non-medical hobby and some friends who aren’t med students (or nurses or doctors).

Make time for self care. If you don’t know what self care means to you just yet, make it a priority to learn. Have a look at the wonderful wellbeing resources put out by NZMSA. Do something to move your body and get your heartrate up at least a few times a week. Eat some vegetables when you’re able to. Make sure your alcohol intake is at a level that’s okay for you.

This is important not only because you deserve to be happy, but also because happy, balanced doctors are safe doctors. Part of your professional development is learning how to live a reasonably balanced life, even in times of overwhelming pressure.

Aim for “good enough” instead of “perfect”

The best thing I have done for my study and mental health this year was to finally take on board the idea that “good enough is good enough”.

Before I started medical school, the concept of embracing average or (in my mind) mediocre work would have appalled me. My drive for perfection is what got me into medicine, and I started the year off believing I could be the perfect medical student. Of course, the spoiler is that I couldn’t - I fell into the same traps of anxiety, guilt, procrastination and avoidance that I did in every other thing I’ve ever studied.

I don’t think this is something you can be told and suddenly ‘get’ - I think it’s a bit of a process for all of us - but perhaps try to challenge thoughts you have that are at odds with accepting ‘good enough’. The NZMSA wellbeing page links to fantastic resources on managing your perfectionist tendencies so they serve you rather than destroy you!

For me, the thing that helped the most was viewing our final exams as ‘formative’ too - what we learn in ELM is really to inform our clinical practice later on, and the exams are just to check that we’re safe to pass to the next stage. Framed that way, they’re not so scary!

You might not be the smartest person in the room (and that’s okay)

One of the hardest things about adjusting to medical school for me was having to adjust to the fact that I wasn’t going to be the best at everything.

I coasted through the short time I spent in high school getting decent enough grades without ever studying. I was first in my graduating class for my first degree. Academic pursuits always came pretty easily to me (anxiety aside).

I’m not alone in this. In medicine, almost every other person is there because they have been one of the brightest students in every class they have been in their entire life.

Sure, you could keep trying to be the best and the smartest, and maybe if you worked incredibly hard you’d succeed. I think being comfortable with being an average student in a class of incredibly bright, driven people around you is a more relaxing feeling.  

Enjoy it!

Former OUMSA president Hilla likes to say “medical school should be enjoyed, not just endured”.

Med doesn’t always feel enjoyable - sometimes it’s amazing but a lot of the time it’s a long, hard slog (and I’ve only done a year of it). Try to savour and make the most of the bits that make it worth it for you. After all, it’s six years of your life - you want to spend it living.

-

This is the first in a series of posts on surviving second year medicine. If you’d like to see more, new posts will be linked to as they’re published here. 

[raspberrystethoscope]

Surviving second year medicine

I’m scared even to write it because it feels like somehow the med school is going to realise it was a mistake, but I passed second year medicine (and actually did pretty well).

It took me half of this year to realise how med works and how I should have been studying all along, and the other half to find motivation to actually do it in the midst of various life things.

I’ve been itching to write these realisations down. There’s a lot to say, so I’ve split it into a few posts. They’ll be a bit boring for non-meddies, and I’m not going to pretend that it’s the only perspective about how to do medicine, but hopefully it might help some up and coming meddies to feel a bit more under control earlier than I did.

1. Top tips for life at medical school

2. The path to being a doctor

3. What to buy for second year med

4. What to expect from ELM2

5. How to study for ELM2

[raspberrystethoscope]

Still breathing

Our bodies use up oxygen and make carbon dioxide every second to keep our cells going. The only way we can get one in and the other out is to keep breathing. We breathe when we’re awake and when we’re asleep. We breathe more when we make more carbon dioxide and need more oxygen. We do it without even having to think about it.

The way we do it is pretty cool. Sensors in our brain and in some of our biggest arteries notice when gases in the blood have changed, and signal for us to take a breath. These sensors notice when we’ve got a bit too much carbon dioxide long before they notice that our oxygen is low. Our cells make carbon dioxide. Levels rise in our blood. We breathe.

It’s not like that for everyone. The story goes* that when someone’s carbon dioxide has been high for a long time, their brains might no longer be sensitive to that signal. We called these people “CO2 retainers” and their drive to breathe relies on not having enough oxygen.

This isn’t much of a problem unless they’re given extra oxygen in an ambulance or a hospital. Without the reminder from the low oxygen, there’s not enough of a drive to keep breathing. Low oxygen in the blood is not a good thing, but it’s keeping some people alive.

I’ve thought about this a lot over the past month. As I’ve mentioned before, things have been rough and I’ve struggled. Out of necessity, I’ve been working on being kinder to myself.

That’s scary, not least because being unkind to oneself is a pretty effective way of staying productive. You know how it goes. Assignment deadline or exam approaches, anxiety rises, an elaborate schedule is created. It is initially ignored, until fear and panic force a frenzy of focused study. The deadline is met, the exam is passed. The cycle begins again.

I’ve been running that way for as long as I can remember, and I worried that suddenly being self-compassionate would be like giving too much oxygen to a CO2 retainer. What if I had become so dependent on anxiety and guilt that without them, I forgot to breathe?

I asked our respiratory lecturer (for study purposes, I swear) what he’d do if a CO2 retainer came into the hospital needing some oxygen. “Oh, give it to them,” he said. “Just keep an eye on them. Take blood tests. Make sure they’re still getting air in and out.”

It’s early days, but I’m getting there. I’m doing some study. I feel calmer and clearer every day. Having enough oxygen feels good. I’m still breathing.

Picture: Illustration from Quain’s ‘The viscera of the human body’ (1840). Photo  by University of Liverpool Faculty of Health and Life Sciences, Flickr.

*The physiology is a tad more complicated than they teach us at med school from what I’ve read, but the exact mechanism is unimportant to this analogy.

[raspberrystethoscope]

The vial

“Hi, I’m Izzy and I’m a second year medical student. I’m going to take some blood - it will involve putting a small needle into your arm, and won’t take long. How does that sound?”

My patient, another medical student, nods. I put the tourniquet on her arm and she obligingly pumps her hand into a fist without being asked. A good sized vein pops up, and I push on it with my finger. I open the alcohol wipe and carefully sanitise more of the area than I probably need to.

I leave the wipe on the skin to mark the vein, like I’ve been shown. I put on gloves and uncap my needle which I’ve already attached to the hub. I feel for the vein again.

“Should I just, um, put it in?” My supervisor nods.

Taking a deep breath, I push the tiny needle into my patient’s arm. I see the blood flash almost immediately. I am so excited I nearly forget to keep holding onto the needle. With one hand, awkwardly, I fumble for the collection tube. I push it into the hub. Blood flows in. Success!

The tourniquet comes off, a push of a button on the fancy needle retracts it out of the vein. Gauze, pressure, sticking plaster, needle into the sharps bucket, gloves thrown away, station tidied. I’ve done it.

I’ve given up trying to explain to non-medics in a way that doesn’t sound weird: taking blood for the first time at a conference was one of the best moments of my life.

We’ve done some cool things in Clinical Skills. I can now listen to heart sounds and have a fair idea that there’s a heart beating in there somewhere. I can take blood pressure with a passable degree of accuracy. I can even percuss someone’s lung fields with my fingers and pretend to hear dullness when my tutor says it’s there. I can do far more important things like take a history and gather information about symptoms, which of course isn’t nearly as fun.

None of this comes even close to comparing to the rush of performing a proper “procedure” for the first time. There’s something amazing about getting to create a temporary link between outside of a person and inside. I’m aware that I sound like serial killer or weirdly enthusiastic piercer, but it’s a lot of fun getting through the skin.

The heavily theoretical content we study for the first two years of medicine can feel awfully tedious at times, in a way that is hard to explain without sounding lazy and ungrateful. It often doesn’t feel like you’re really going to be a doctor when you sit in lecture after lecture of impenetrable ‘hard science’ content. The days seem long, the exams seem impossible. One weekend at a conference, two minutes with a needle in my classmate’s arm and a single vial of blood made it all feel worthwhile.

I’ve managed to go to all my classes for two weeks on the strength of that vial of blood. I may well pass my exams on the strength of that vial of blood. If I end up actually becoming a doctor, I will owe it in part to that vial of blood, and the arm patient that provided it. Thanks Emilie!