The Leodisian Life...

[yeliab_cram]

Just like the first time you cut into a dead body, the first time you go on the wards and the first time you see and operation, doing your week on labour ward is a key landmark of your medical training - particularly if you own a penis.

The horror stories are rife. Now there are a number of problems here. Problem the first: obstetrics and gynaecology is not a fun place to be a man (no matter how hard a squeeze and try to create a uterus its just not happening). Indeed every surgeon you meet will still pull the most awful of faces as they remenice when you say you are doing O&G soon. I mean come on, looking at vaginas all day is just going to be grim. And lets be honest, half the time they are going to be icky diseased ones at that. The additional problem is that the lack of a cervix means a lot of women are not all that keen to have to staring at their netherregions whilst they push out baby, blood, amniotic fluid, and quite possibly a turd. And if they are, daddy probably isnt.

Problem the second is the absolutely horrific reputation of midwives in their treatment of medical students on labour ward. Some consultants can still remember the names of the bitch-midwives that made their life hell on earth.

You see a large part of the problem is the timing and the competition. You start on delivery suite at 7am sharp (this, of course involves getting up at half past five and already things are starting off on the wrong foot). The next problem is that there is a finite ammount of product (ie mummy in labour) at any given time. Finally there are a number of medical and probably midwifery students around all wanting or rather needing to observe and perform deliveries. Hence we have supply and demand issues all around the town. As a result, large proportions of deliver week are famously spent sat in the office making tea.

Despite this fairly dreary outlook of O&G and particularly the delivery week i have to say it is not going at all badly so far (but it is only wednesday and i am already struggling to function). It appears that the midwives in the LGI are not actually the evil fire-breathing spawn of dale winton and a horse but in fact quite a decent bunch who can be tamed by the continued production of tea (brewed in a pot with 4 teabags, not 3).

I do however feel the urge to introduce myself as "Marc, and yes, i know, i dont have a cervix but..." although there is at least a male SHO to help dilute the whopping great pools of oestrogen. Perhaps the biggist problem with my maleness thus far is in the changin room. Due to the lackage of men, there are no shoes, and no decent sized scrubs in the mens changing room. Which means i have been wandering round for 3 days now wearing white wellies and either very baggy or very tight blues - lovely.

Timing is a problem. Statistically women are most likely to give brith at 4am. Hence arriving at 7 means you consistently miss a chunk of the action. However its not all bad. When there is nothing to do, there are often fun people to play with in the office. For example the other day one of the SHOs showed me that if you wear XXXL scrubs bottoms, you can pull down the crotch do its at your knees and then slide around the office on the wheely chairs like your out cruisin' in da hood... hmmm.

So the miracle of birth then! well i must admit it is quite horrific. Nobody really warns you about the blood, shit and other fluidy things. And the babies when they pop out are just icky, i mean they really are just unpleasantly gross, particularly when they are overdue and incessantly shit when they are born! However once you get over that, it is quite amazing, paricularly when the couple appreciate your presence. Although i use the term couple lightly, as more often than not there are issues there. Either there is no couple, its turns out dad isnt dad or there are some serious differences of opinion between the two wonderful budding parents.

Anyway, its time to go and veg in front of the telly. I have to be up in 8 hours, woohoo. Ah well, its not as bad as gynae is going to be. Blech.

[yeliab_cram]

So... Gynae-****ing-bloody-cology. It is the significant low point of a young male medical student's career. Its grim. Im just shocked that we dont receive any training on how to have "the" conversation. Come now, you know the one i mean. It is the conversation with a patient that every male medical student secretly dreads.

You see as a medical student it is simply expected that as part of your medical training you WILL perform X number of viginal examinations. Back in the day, one would just examine the women whilst they were out cold on the operating table. However someone has obviously realised that this isnt really cricket, and it is now of upmost importance that one gains appropriate consent from the poor woman involved before hand. As i am learning it is also probably best to document this in the notes and get the patient to sign it about 37 times. You cant be too careful.

So the conversation itself. You see there isnt really a particularly glamarous or unembarrasing way of asking a complete stranger if it would be ok with them if you molest them whilst they sleep. As i lurk around the ward at 8am (after ending up on a renal ward at the opposite end of the hospital, because some ****ing manager decided to move the gynae wards to the opposite end of the hospital last week) I cant think of anything i have ever wanted to do less than what i am about to do.

I am shocked, geniunely shocked, that despite our countless PPD sessions in the early years about how to be nice and care about how people feel and blah blah blah, nobody has every thought that it might be a good idea to sit down and run through how we should go about consenting women for this particular scenario. I mean its just a case of learn as you go along.

I have to be honest, it really has not been anywhere near as bad as i imagined. In the words of Yazoo on another thread, you just have to do it like you are asking directions to MacDonalds (i dont know why one would be asking anyone for directions to maccy Ds but thats a different story). Anyway, most of the women are very understanding and are actually quite ok with what you are asking to do. Even so, it is still a difficult conversation as a bloke, and each time you do it you have to win a mental battle with yourself between getting this done, and going to home do anything else, including clean the bathroom.

No wonder very few men go into OBGYN these days. BBBLLLLEEECCCHHHH!!!

The men that remain tend to be from a different age. They don white coats for clinic, refer to the medical students as "doctor" which, i'll tell you now leads to no end of confusion. And they bark, quite randomly and often in latin, at you. For example, after spending several hours in outpatients with my lovely consultant, he sent me to see a new patient, who was in a rather pissy mood and most definately wasnt best pleased to see me, but whom i took a history from and presented. Now It was already quarter to six at night and another medic had a case to present next, so after we had seen my patient, i decided to, very politely try to get out of clinic and go home. It went like this:

Me: Mr Ageing Gynaecology Consultant, as my colleague has a case to present to you would you mind if i shoot off now as i have a meeting at 6:30?
Ageing OBGYN Consultant: Young man, you will do nothing of the sort, the clinic is not yet finished. You WILL stay until the end!
Me: Excellent.

So all in all i have learnt this: i dont want to be a gynaecologist. Vaginas are gross, especially when they have fishy exudate leaking from them. Or when things are prolapsing through them, like babies. Im going to stick to being a man.

[yeliab_cram]

At the moment i feel a teensy bit like im stuck in groundhog day. Despite the fact that we rotate round onto a different firm each week at the moment (and this involves changing from the LGI to Jimmies and back again on a weekly basis) I seem to be stalking the same 4 SHOs. Initially i thought this was just an interesting coincidence, but today over a cup of tea with my consultant i realised that it is perhaps an interesting symptom of life in the modern NHS.

Back in the day, when nobody even knew what political corectness ment, let alone gave a shit about it, house officers were effectively owned by a particular consultant. They were in essence his (and it was always a man) house dog. As a result, it was in the interest of the consultant to mould his newly appointed mongrel into an efficient and effective diagnosting-treating machine. It was, in essance a mentoring system.

However with the introduction of the EWTD and MMC junior docs spend fewer hours on the wards and are attatched to a specialty team rather than a specific firm. What this means is that each SHO is constantly working for different consultants - who most likely all like things doing in a certain disperate way. Additionally, they stay in this post for a vastly shortened length of time. What this leaves us with is a system where it is very hard for any particular junior doctor to get consistent training from his or her seniors.

The same argument can be made of medical education. A few years ago the fourth years were doled out to various firms in the O&G department to spent four weeks with them. In this time there was the opportunity to build a rapport with the team, and in turn, for them to evaluate your performance. However i am now lucky if i get to see my consultant twice in a week.

In addition to this, i have experienced another problem this week. One which i never would have expected. As i am sure you gathered from my last post, my mission at the moment is to first consent and then rather intimately examine a certain number of female patients in order to become competent in VEs before i am turfed onto my next attatchement. The best place to practice these is in theatre.

We have a number of theatre sessions each week both in the day case unit and the inpatient lists. Yesturday i was in the day case unit, where there would usually be between 5 and 8 cases in a single morning or afternoon session (depending on the nature of the cases). I was scheduled to be in the unit all day. This should have given me the opportunity to do at least 4-5 examinations (as there were 2 medical students). However i was shocked to discover upon my arrival at 8am that the first list was cancelled and the second list had a mere 2 patients on it.

It was only when sitting in the coffee room with the consultant later on that the reasons for this lackage of teaching materials (or patients as you may know them) was revealed. Its the end of Feb - we are getting close to the end of the financial year and the PCT cant afford the operations any more. So despite there being a long waiting list, a free theatre, free theatre staff, a free consultant, registrar, SHO and even medical student, there are only 2 patients booked in. What a ****ing joke!

Anyway, end rant. Despite the reduced numbers, i was lucky enough to be in theatre with Mr Simpson, who is just a thoroughly lovely bloke, and a fantastic teacher. Whilst some consultants can make you feel a bit silly when doing your VE (as the entire team stares at you waiting for you to just get on with it) he was very keen to teach, and help me improve my skills with a speculum (or as i like to call it - ducky). It makes such a difference to your day if people make you feel part of the team rather than a burden on their lives. And i think, for the first time in gynaecology i am actually enjoying myself. Shocking.

[yeliab_cram]

In response to much demand by so many people, namely (well in fact solely, Wendell) i feel it is time to make more random and slightly cynical ramblings.

Since our last meeting i have progressed from POG to PPP. Officially my own personal worst nightmare. It is an amalgum of publick helth (meh) psychiatry (d'oh) and primary care (zzz) mixed in with ample helpings of PPD - personal profesional development for those who have missed previous rants (aah) and I&P (crap). Leaving a rather congealed icky, goey, boring, repetetive treat which is highly unpalatable for the budding surgeon.

Well that might be a bit harsh, but i shit you not, the introductory lecture week was so bad that i contracted an appaling viral gastroenteritis for 2 days which allowed me to bond with my white porcelain friend in its natural habitat: the bathroom. I never knew i could projectile vomit spring onions up a wall - but i can, and its gross. D&V is not fun.

Anyway, first day of GP land today. I think if you could concoct the exact opposite of what i would like my career to be it would be the rural GP i am with. I am in keighley, which, for those of you who are not up on your Yorkshire geography, let me tell you is a LONG way from Leeds. Not only is it a long way away, but there is no particularly logical way of getting there without being buggered by traffic. However, the drive does allow lots of sheep gazing, some cow spotting and horse watching, and the opportunity to drive through a world heritage site, and lots of hills which make your ears pop. How many people get to do that at 8am to the sound of Chris Moyles eh??

On arrival at the practice, kind of balanced on a hill in an old mill, built with the very hands of 1 out of the 1.5 GPs who work there in 1995 along with his dad. His sister is the practice manager and various other family members do various other jobs. Its just a tad... rural.

I first noticed the slightly different patient demographic, when the first five patients were all farmers' wives with varying degrees of knee or shoulder injury due to lambing! And again when i saw one of the patients at the bus stop 6 hours after seeing her (topless i might add) in the clinic.

Actually, its quite nice, they are all very welcoming, and i even got a walking tour of the village with grandad... bless. And in all honesty, its not so bad, it is not ALL coughs and colds. I mean, there are a fair share of them, but there is other stuff too, and it is really quite comforting to get back to some general medicine. After all these specialties it is nice to know about what is going on, even if it involves dusting off areas of my cerebral cortex that i had forgotten even existed.

Somehoe it always comes out fairly quickly that i am surgically inclined and have an interest in vascular surgery and carotid arteries. And today, for the first time since intercalating (well apart from a very useful conversation with one of the gynae consultants, who thought it was all very interesting) it was actually geniunely pointful.

I got to see a patient who had recently had a carotid endarterectomy (done by a surgeon i know at Bradford as it happens, who once emailed me to tell me he has started doing endarterectomies "my way" when he is bored on Fridays, after hearing me present last November - but i digress) and was now complaining of pain and numbness over his mandible. Isnt it great when you have read every study every published (dont worry there arent actually that many) on nerve injury post CEA. I was the font of all knowledge, it was great fun! However after that, each time a patient required a surgical referral, the GP referred to the surgeons as "your lot."

I've decided i need better camoflage in future, tomorrow im wearing chinos, a t-shirt and my walking boots so i blend in!

[yeliab_cram]

Im afraid i cant keep shtum about it any more. I have tried not to rant about it and just be bitter, but after seeing the last 10 minutes of question time this evening with Ms Caroline Flint talking out of her arse, i cannot hold my peace any longer.

Modernising Medical Careers, what a fantastic idea. All those bloody public school consultants only appointing the best rugby players and sons of their friends at the country club to work for them. How outrageous. How can such a system operate in modern britain??? Well it cant, and i dont think anyone other than Mr Blair et al thought this was really the situation.

There were problems with the old job application system in so far as you had to take or decline your jobs at the interview, so it was a real gamble if you got offered your 5th choice job and turned it down only to never get another interview. However there is much to be said of the "appreticeship" method of learning your trade, which is now sadly departing all too rapidly from all spheres of medicine.

Training in the NHS has long been regarded as some of the best in the world. Mainly because trainees worked for the same boss for 6 months or so, during which time it was in his own interest to train this young doctor to be as good as he could be. So that he could trust him with proper work. The consultant would know what the trainee was capable of, and what needed work and a rapport was built between the two.

However Labour has promised more consultants. Lots more consultants very soon indeed. A system of apprenticeship takes time to get you your consultants. You see its far quicker to have a list of 'minimum competencies' that your training doctors must be able to acheive at each stage and then kick them to the next step as soon as is humanly possible. Whilst this reduces training from 14 to 11 years, it profoundly weakens the quality of that training. ST trainees will pass from pillar to post, working with different consultants each day and having to prove themselves to each in turn. They will not gain their trust and consequently will have less responsibility and will as a result become more demotivated.

This in itself is bad enough. But then you have to factor in the MTAS debacle. The idea here was that all doctors should be garuenteed a job somewhere in the UK and that it should be possible to apply for a job anywhere you like without bias. Now this is essentially a very "nice" idea. only problem is, the MTAS form is completely devoid of any worthwhile information. It consists of a number of short statements, which refelct, not extracurricular activities you have been doing over the last 5 years of university but how well you can blag. there is little credit for academic acheivement or excellence. In fact the playing field has been so flattened, that essentially all applicants are the same. As a result the best and brightest are missing out on the jobs they deserve.

The logical end point of this is this. The best training doctors will go overseas or leave medicine, reducing the quality of the end product. Those who do stay and make it through will be vastly inferior to the current consultants and will require their support to practice sucessfully. Trainees will be able to do less and less without supervision. Ultimately consultants will end up doing everything - from clerking to 10 hour operations and everyone else will be reduced to what was once senior medical student roles.

I am the first to admit that the NHS has always had problems, so long as i have known anyhting about it. But right now it is on the brink of collapse. Morale has never been so low across all grades of doctor and across all allied healthcare professionals. The government is ****ing us all. Even us students have escalating debts and no job security. For me, its a real shame. We have a fantastic healthcare system that is free at the point of acess, yet the care provided is on a par with the best in the world. It is a fantastic ideal and something we should be proud of. It deserves to be fought for and it is sadly ironic that it is a labour government who are putting the nails in its coffin.

[yeliab_cram]

So this is my 1,000th post on NMM, thought i would celebrate that fact by telling you quite possibly the most depressing story i have every heard. I saw a woman today, the same age as me, and in all honesty i have never felt to sorry for another human being. I just wanted to give the poor girl a hug - but i dont think thats the done thing.

I often find it a little close to home when i see patients who were born in the same year as me yet lead a life so different that one wouldn't belive it was possible. I think this first really hit home on labour ward, but nothing like it did today. I called in the next patient, whom i noted was my age. She had no medical history of note, and the only regular prescription she had was for the pill. I assumed, in my infinate nievity that it was going to be a consultation about contraceptives.

I couldnt have been more wrong, i was presented with someone who had been assaulted, repeatedly, by her so-called partner, such that she had had to run away to her parents' house, but as her partner knew where that was she was going into a woman's refuge for her own safety. Oh did i mention she was newly pregnant after a spate of miscarriages.

It wasn't the first time he had hit her, it had been going on for years, but she had finally decided to take action against the bastard. And she was shit scared. **** me, i would be too. Hats off to her, she was keeping the baby and getting on with her life, but it was clear to me that he had already crushed her spirit.

When she left the room, i just sat there. I have never really been at the business end of such a consultation and actually appreciated what that sort of abuse does to someone. It made me ashamed. Not of myself, but of society, of all of us, collectively, together. Its the 21st century, how does this still happen. I'm poncing around playing doctors and nurses and she is getting the shit beaten out of her. But 23 years ago, who knew which way it would go for either one of us?

[yeliab_cram]

So, psychiatry eh, the nut house, loony bin, insane asylum. Shame i'm on old age psyc where everyone is either depressed, demented or both. Maybe i'm just a bit of a cock, but i find mentally ill patients difficult. Once you start getting into things with them, its not so much an "illness" as a lifelong problem, often instigated by some horrific experience long in their past. As much as i feel bad for them, i cant help but want to get them to pull themselves out of it rather then giving them some more prozac.

Going into the Leeds Mental Health Teaching Trust HQ, is not quite as bad as one would imagine from watching one flew over the cooko's nest, but there are definate similarities. On my first day i took a lady into a side room to interview her. Half way through an elderly asian lady came in, came over to me, said "salaam" and sat opposite us and just stared. Didnt say another word, or respond to anything i said to her for the next half-hour. Then suddenly she just left.

Anyway, i have been going on tollerantly enough through all the rather dull depressed patients. I dont like psyc, but if i have to do it, id prefer my patients be completely mad, rather than just extremely depressing. Its making me depressed! Finally my prayers were answered when i met Larry (i have changed his name dont worry).

A long suffering manic depressive currently on the crest of a high. Not only does he tell me he's commodore of the navy, but makes me a corporal and makes me salute him every time we pass in the coridoor. He owns sainsburys, the crucible and half of Scotland. He is married to Helen (of Troy) claims to be "the man from the pru" a communist MP in 1952, a doctor and dentist in the navy. Of the royal blood line: the great great uncle of lady Di, twice removed on her mothers side, apparently and he went to school with Arthur Scargill. Wow. What do you say to someone like that? I think i did what you have to do, and just played along.

Saw him on the ward round today, and at least the joke he told us all made sense, so one hopes he's on the mend.

However Lary is not what has impacted on my mental health today. No, it was instead an SHO who i used to know when he was at medical school. He was the best. He was super keen, super intelligent, super-medical-student really. Very keen on A&E, he lead the SJA unit at Leeds, and is now in charge of the programme. You could have put this guy in A&E in his third year and he could have kept up with the registrars. More than that, he was so optimistic, nothing could ever knock him down. Even when he had to do a job in paediatric surgery and psyc in order to get a job in A&E. The man is untouchable. until i saw him today.

The NHS has taken his spirit. This man, who is the perfect candidate for an A&E ST post. He has taken his part I, ALS, ATLS and is very active in prehosp care. One of the top in his class, numerous publications. He doesnt have a job. How does he not have a job? If im dying in A&E in 10 years i want him there. If he, who was "garuenteed" a great job doesnt have one, we are all ****ed.

Why is this happening?

I'll tell you why: "Tony can't afford the NHS no more. He's paying for the Olympics and another bloody war." The Amateur Transplants.

[yeliab_cram]

I have just recalled a Douglas Adams (RIP) quote which, i think sums up absolutely and completely my feelings on psychiatry at the momenet. I thought i would share it with you:

If somebody thinks they're a hedgehog, presumably you just give them a mirror and a few pictures of hedgehogs and tell them to sort it out for themselves.

[yeliab_cram]

Congratulations to me... its my birthday, yes thats right, time to pat me on the back and say "well done, you did it, survived for another year." After giving myself the morning off (/ultimate procrastination) i decided that i should face the music and go and see the 4 psyc patients i need to see before the ward round with my consultant.

My Consultant had asked me to see his new patient, who we shall arbitrarily call JJ. I knew it was going to be "interesting" after seeing her in the ward round last week. I can only describe her as stark raving bonkers (thats my best PC speak): "there's plenty of psychopathology for you to elicit there" suggested the consultant... excellent.

So i wandered into the Mount (amid screams from a dishevelled old man sat outside) and marched onto the ward where my first patient was. "She's in her room" said the nurse. So off i popped. She wasn't in her room. She wasn't in the lounge either. She must be in the toilet.

"hello?? Mrs JJ?" i asked through the door of the loo. No answer. "hello?" nothing, then some shuffling. Then she appeared. "i'm on the toilet" she said, and went back in. Fair enough i thought. I'll wait here. 5 minutes passed, then 10, then 15. i waited. There was more shuffling. I waited some more.

After 20 minutes she appeared... clutching something in her right hand. "wonder what that is" i thought. She held it out to me. "do you want this?" she asked. What she offered me was not a malteaser, it was not even two malteasers. It was a turd, balanced procariously on a carefully folded blue paper towel.

I was proud of my response. I did not gag, vomit, laugh or even flinch. I simply replied "not really; shall we pop back into your room" - deal with the shit later i thought. Then my phone rang.

Poo is possibly not the best birthday present i have ever received.

It was one of those wonderful consultations where its so absolutely insane that the only thing you can do to sucessfuly converse with the patient is to accept there vision of the world and discuss matters such as "the transponder" which sends thoughts to "the microchip in her head" as if they are as normal as cricket.

I found it quite touching when she cried that she couldn't see her husband because he had been taken to the LGI with anal tuberculosis (?!). I did find it interesting that although they had been married for 33 years, she had not seen him since 1977. You see he lives in the flat above her, and cant leave it because he is a cripple. She cant visit him because she is also a cripple. He speaks to her through the transponder. He loves her very much. Oh, also, he's a complete fabrication.

She has survived (got knows how, because this is actually true) on a diet of milk, porridge, tinned fruit and branflakes for almost 15 years. If she uses the cooker she will have a heart attack... this is because she is radioactive.

I could go on, but i wont.

You see, i could be disgusted that i got handed a lump of shit, but actually i think its great. Psychiatry has been so boring. I was expecting axe murders and psychopaths and people who can communicate with god etc etc etc. However 90% of what i have seen is depression or just simply depressing. So it is great to have some insanity kicking around. Think i'll visit her again tomorrow. Maybe i'll get some vomit. Or a shoe.

[yeliab_cram]

Everyone always says fourth year is the worst, longest and most demorolising of your undergraduate medical career. You are at the outer reaches of what you need to know - the furthest you will ever need to go, before returning to the relative normality of fifth year. Right now, we are currently just rounding the far side of fiji, ready for the blast back home.

I must be honest. Whilst it has dragged a bit, it hasn't been than bad. Until now. We have been at uni this for 47 weeks. Thats a really ****ing long time, especially when you have been at uni for 5 years already. Its not just the length of time, its the silly ammount of stuff they seem to want us to know.

One moment we shall be debating at how many months a baby can play peek-a-boo, and the next discussing the most appropriate hip prosthesis to use following an intertrochanteric NOF (neck of femur) fracture in a LOL (little old lady). When you actually see it written down it is a bit daft. They expect us to have a comprehensive knowledge of:

Orthopaedics, rheumatology, dermatology, anaesthetics, emergency medicine, rehab medicine, infectious diseases, genito-urinary medicine, gynaecology, obstetrics, paediatrics, psychiatry, primary care and to add insult to significant injury: public health (i mean what the **** is public health??)

and in typical medical school fashion, they are unlikely to want us to know things that would be useful to our future careers. They prefer us to be able to recount such memorable conditions as elhers-danlos, brown-sequard, osgood-schlatter and of course the similarly eponimously named clinical signs such as argyll-robertson pupils and rashes which exhibit the auspitz or nikolsky sign.

You have to admit, its not really that cruical to my life that i understand the foundations on which psychological illness classifications systems are based (did you know DSM-IV is a multi-axial classification system? well now you do).

All i can say is this: it shall be strangely pleasant to return to the relative normality of life in general medicine and surgery. maybe all this random eponymous knowledge will impress one of the general surgeons? shame adults dont tend to get kawasaki's disease... oh well.

What will be more pleasant however, is to have done these nightmare killer two-day-osce-six-hour-EMQ-and-a-slide-show exams. AAAAAAAAAAAAAHHH!