Monday, 29 May 2017

Sound and Fury Signifying Nothing

I forgot I was at home earlier, and went to reach for my call room key in my purse.

It's been a long few days and I'm really tired.

Right now Im trying to get a ton of paperwork stuff done because that's life.

My husband is going to be returning to work part time next month when his parental leave is up, and then full time in July. Our older two kids are going to be going to spend much of the summer with their grandparents, so conveniently we'll actually be down to just one kid for all of July, then we're back home for two weeks (vacation for my family, elective for me.)

We've decided to do this as a means of limiting our overall debt. Our original projections took into account that I'd be applying to the sponsorship program and while it was obviously never a guarantee that I would be accepted for it, I'm pretty sure at this point I won't be applying to it because I still very much want to go for OB/Gyn.

Well, usually.

I find on post-call days, particularly when I haven't had any sleep, I lean pretty heavily towards just going for family med because it's a specialty that allows for much more sleep and a better lifestyle, and at the moment, that is incredibly appealing.

But it's kind of like that whole "don't shop hungry" idea. Don't make career-modifying decisions whilst exhausted.

Family med has a lot of customization, it really does. You can tailor your practice in many ways, but it is still primarily a medical specialty with some occasional procedures and maybe, maaaaybe some surgical assisting.

I want more than that, and I know that if I'm going to have the stronger emphasis on procedures and surgery, I need to go for OB.

But ugh, sleep. Sleep is nice. Being home for supper with my family is also nice.

Yet... surgery.

There's the rub, and that's why I've been going around and around and around.

Which is making me even more tired, so I'm going to go to bed now and stop thinking about it until tomorrow.

Unrelated to anything: my cat looks like he has a side quest for me. 

Tuesday, 23 May 2017

Sundowning


The title of this post is a medical phenomenon. Patients with dementia or delirium sometimes go through something called "sundowning." Towards the end of the day, they begin to get more confused, more agitated. Sometimes combattive. It's quite the challenging phenomenon to deal with, and it is hard for the patients.


I wrote most of this post late yesterday, when I had retreated back to my call room after a consult. The anticipation of the pager's shrill beep was keeping me awake during that precious potential sleeping time, and my mind would not shut off. I was agitated. I was frustrated. And I was so tired.

Usually, I find sundown to bring a lot of peace. The transition times of day - as I watch the sun fall off the edge of the horizon and as the earth rotates to reveal it once again - have always been my favourites. I'm someone who finds strength in quiet.

Years ago, I started making a habit of going outside at the break of dawn with a cup of tea, sometimes a cat, and breathing in the fresh, clean morning air.

I don't think that's likely in this city, but as I wrote the bulk of this post last night, I made plans to find a quiet corner high in the hospital to enjoy a coffee and watch the sun rise over the city. That didn't happen, as I slept through my alarm and was late to handover, but I intended to find my way to the hall outside the teaching room, where large windows look east. That meant first getting through the night.


Overnight, the hospital halls are hushed and still in a way that is so at odds with how people usually see them. I remember from the parts of my childhood spent in the hospital that it reminded me of an empty church. It still does. My father is a minister and so growing up I spent a lot of time in empty chapels; walking between the pews, hearing my footsteps echo off the angled ceiling. I was allowed places parishioners often were not. After the service, I'd get to drink the leftover communion grape juice from tiny glasses. I'd play with the organ. Knowing the church in emptiness felt like being in on a grand secret.



Most churchgoers only ever see the chapel at its height, teeming with life or celebration or clouded by tears and grief. Most patients experience much the same of the hospital; they have visited sick family members, they have grieved in the halls, they have perhaps celebrated new life in the one ward for functioning organs. But they have not known it in the stillness, even when they have stayed. Like the chapels of my youth, walking quiet corridors deep in the night feels like a privilege; a trip down the fairy way into a different world.


There is a certain smell and a particular acoustic quality to many churches. These are branded in my memory as markers of peace. While I left the faith in my teens, I do have pleasant memories of hours spent sitting on the carpeted dais and hiding in the secret places parishioners don't go.

The difference, of course, is that the hospital at night is far more populated than those chapels I explored. There are nurses walking as quietly as possible to and fro, people paging, monitors beeping, nighttime medications to give or vitals to take. The hospital is never still. It is never fully at rest. But like the churches I knew, is a place where families change and death and new life are both addressed plainly. It is a place of transition.

The room I spent last night in smells like an old church, which is what brought this all to mind. As I walked the corridor towards my nominally locked door, the soft thump of my footsteps echoed in just that right way to remind me of my father's steps down the annexe hall. I lay in bed in my call room, unable to sleep, but listening to the creak and grumble of unwilling pipes that were old when I was born. Like evenings spent in the sanctuary as my father fixed something or set up some new system, or as the women toiled at some project intended to help the world or the community, I rested without sleeping. As I child I would sleep anywhere, but my curiosity often kept me awake. That's still a problem. But as with then, I seek out the quiet places where my mind can settle.

I watched the sunset from the eighth floor windows yesterday. As I looked east, the sun behind me, I saw the broad brush of orange light paint this industrial city vibrant for a short time as houses nestled in the shadow of the hospital stared back at me with undressed windows.

For a short time, I found some peace, and I stopped to enjoy it. The hospital is both a cage and an endless world of new experiences for us. Life under the microscope of constant evaluation, constant assessment and reassessment of how well you are adhering to the plan for how things should go; whether as a learner or staff, it is challenging. But I found a moment yesterday, I stopped and for a time felt peaceful, and I thought about how hard I have worked to get to that eighth floor hallway, in my scrubs, my stethoscope heavy around my neck, the weight of responsibility in between the pages of the chart in my hand.




The sound of a siren in the distance reminded me I had a job to do. The papers in my hand, a dictation waiting. It came easier this time. It will keep getting easier, they all tell me.


When that was done, I made the pilgrimage back to my room, and listened to the silence, in search of peace, awaiting sunrise.



The juniors residence is visible in this photo. As is Miss M, who made my morning much brighter. 
.

Sunday, 21 May 2017

Unwell

I'm not doing terribly well right now. I can't focus on a damn thing. I'm reading sentences multiple times and still not retaining sufficiently so I'm spending hours and hours and hours pounding away at my study materials and I'm getting nowhere and I can't recall things which I absolutely do know. It's very frustrating.

There's actually a physical reason for this - going through workup, but basically right now I'd be a great OSCE station and the labs and imaging are more to confirm what's already pretty obvious - so I know I'll be doing a whole lot better once I get that side of things worked out. It's actually probably why I've been so flat out exhausted for months. But that doesn't make it any easier to cope with the fatigue and brain fog in the meantime.

This is all very difficult because I normally have extremely high retention for what I study and I've never had to brute force study like this, but my mind is so foggy right now that I'm actually having a hard time with basic day to day tasks. This is much worse than the third trimester 'baby brain' and I felt like an idiot with that.

It also doesn't help that while I'm dealing with absolutely soul-crushing fatigue, I'm about to start a 26 day stretch of work (three weekends in a row) with 7 call shifts in there, so I kind of want to curl up and cry. Post-call days are still work days. I don't leave until 10am post-call, which means I've worked ten hours on that day. So yeah, I still count post-call days as work days. My next day off is June 17th - the second last day of this rotation - and I've spent this entire weekend studying so I basically haven't had it 'off.'

Honestly I'm having a hard time finding any time for self-care. Okay, I'm not just having a hard time, I have had precisely no self-care time at all. I've barely seen my kids this rotation so I feel like if I'm not studying I should be with them, or taking some of the load off my husband, but I'm minimally functional right now right now and am saving all the energy I can for work.

I'm sure it's pretty evident by my posts lately that my mood is in my boots. I've basically spent all of today holed up in my office trying to study and failing miserably because I can't remember anything, so I've spent the last two hours starting at this stupid SIMPLE (online training) case feeling like the biggest idiot in the world because I just can't remember anything. And I'll feel like more of an idiot when I can't answer at the drop of a hat what the mechanism is for whatever drug that I read about six months ago and have never seen used clinically.

I've tried to write a post about this a few times, and have failed. I'm not even sure I'm going to post this one because I've been doing a lot of complaining lately, and this is what I signed up for so I really shouldn't.

I'd be lying if I said the thought of just leaving med school hasn't crossed my mind. I wouldn't, I never will, but damn it's tempting right now to just say 'screw it' and walk away from this and not feel stupid anymore and have to work 10-16 hours a day for a almost a month straight.

I'm trying to be positive. It's only four more weeks. It's only four more weeks. I will come out the other side of this with much better essential skills and knowledge. This is a critically important formative experience for my future as a physician.

This will make me stronger. I know it will. I just have to get through it. A month is nothing in the long run.

But it's a long month, looking at it from this end.

Sunday, 14 May 2017

Blows

I am a very anxious person, always have been. I tend to get stuck on seeing the worst that can happen and occasionally I'm paralyzed by that anxiety - this has been particularly bad during my current rotation where, during my day-to-day clinical activities, I'm freezing on what to do.

The funny thing is, though, that in an emergency I'm actually very calm, collected, and I'm comfortable taking control of a situation if it is appropriate for me to do so.

I've gone through first aid training a number of times, and I think that helps, since I've been this way well before I started medical school.

Today my youngest - she'll be 7 months on Tuesday, which is incredibly hard to believe - was having some eggs and started to gag. Then she stopped gagging and just moved her mouth a few times while looking at me. I whipped her out of the high chair, cleared her mouth, inclined her downward over my arm with her mouth open and delivered five hard back blows. She started crying, but it was soft, so I did it again since I felt she might be partially obstructed. She brought something up in her mouth and was none too happy but seemed okay. I took a listen to her lungs, and all fields seem clear and I don't think we need to take her to emerg. I'm studying (well, I'm on a scheduled 10 minute study break right now) so my husband is watching her carefully and if she seems off at all, we'll bring her in.

Thing is, I didn't even think about it. Even with relatively little experience - I've only had to do this once before and it was nearly ten years ago - I still just shifted into the problem-solving algorithms I was taught. I didn't panic, I just got to work.

It's funny how I can be someone who panics at the sight of a bee but when faced with a scary situation, I'm fine. I'm so anxious about my kids getting hurt but when it comes down to the line, I don't feel a second's guilt about hitting my infant hard on the back to clear her airway.

At my stage of training, within the hospital the vast majority of the time my role during a code is "stay the hell out of the way until told to do something" and then probably doing compressions because apparently med students are the muscle during codes at this site.

But outside of learning situatons, I have had to manage emergencies/urgencies - babies choking, person passing out in front of me, witnessing an assault, kid having a seizure, amongst others - and I've been totally fine. Assess the situation. Call for help. Give individual people single instructions. Get to work.

This Mother's Day, I'm grateful for the fact that I have skills which help me keep my kids safe. I'm grateful for the fact that my husband does too; that in an emergency, I know he will be equally quick to put his first aid training to use.

I'm reminded that my job as a mother - like my job as a soon to be physician - is one not only of guidance but of protection, and sometimes you've got to hurt to help and anxiety be damned, I've got a job to do.




If you are someone who cares for young children, please make sure you have first aid training and ensure you have taken infant CPR so that if you are faced with something like today, you will also be comfortable knowing what to do.

Friday, 12 May 2017

Within Doors

First week of internal was... probably my worst week of clerkship so far.

Well, there's no 'probably' about it.

Basically, my anxiety got the best of me and I froze up at every possible opportunity to demonstrate any sort of skill. I stammered a lot. My presentations were awful.

I just, overall, completely sucked as a clerk and basically made more work for everyone.

The way the CTU schedule is, we really have about 3-5 hours a day of clinical time. The rest is spent in teaching or meeting with our team (new patient rounds in the morning, running the list throughout the day, or handover.)

I lose about an hour of that because I need to pump. My pumping room (a call room) is in the juniors residence which is on the first floor in a different wing, far away from where I'm usually working. I'm down to two pumping sessions a day, but still, adding in time to get there and back, plus pumping time, plus time to wash my stuff, and I lose over an hour of that clinical time, and I can't run off during other activities.

So between my absurd level of sleep deprivation, my sky-high anxiety about doing poorly on this rotation, and the fact that the issue I've been trying to see my doctor for since February is getting worse, I'm basically a stressball at the moment. I'm that harried, slightly crazed-looking med student who is muttering to herself and stumbling over words while presenting.

In short, an absolute mess.

This is burnout. I'm actually a very strong student with a very solid knowledgebase. There is absolutely no reason my reflex should be to say "I don't know" about things I'm 95% sure of, but I still do that because my anxiety gets the best of me.

I'm also in too much pain to bother putting in the effort some days. Looking up the ridiculous name of an obscure trial so that I know the answer to some trivia question the next morning is really not high on my priority list. Absolutely I need to keep up on medical research and I need to be critical of evidence and stay on top of guidelines and why they are the way they are... but that's supplementary to, not in place of, what I need to work on right now. Preclerkship helped me build the foundations of my medical knowledge. Clerkship is building the walls. Residency is deciding on all the fiddly bits and doing the decorating.

I'm coming out of my first week of internal feeling very defeated and exceedingly stupid. No one was unkind to me at all; in fact all the staff and other learners have been very kind so far.

The very last day of my program is less than a year away, and honestly I've never felt less prepared than I do today.

Logically I know this feeling will pass. I know I will get through this, I will learn, and I will be fine because I always am and I tend to 'anxious' myself into a far bigger mess than I have any right to be.

But anxiety isn't logical, so despite logically understanding that like all things, this too shall pass, it's still hard until it does.

I'll get there. Just not soon enough.

Tuesday, 9 May 2017

Eep

So day one of CTU and I'm basically deer-in-headlights level terrified, feel completely out of my depth, and feel like all of my classmates - many of whom have done CTU electives and so actually have some idea of what we're supposed to be doing - are way, way better off than I am right now.

I need a ton of study time because I basically need to review the entirety of the last nearly two years because I feel like nothing at all has stuck in my mind.

Study time is one thing I don't have.

We got our tutorial topics for tomorrow at nearly 8pm. I've been studying, but just do not feel like I've even begun to appropriately cover anything adequately for tomorrow, and I'm on call tomorrow.

Time management has always been my forte. I'm good at getting stuff done, at prioritizing, but I have no idea how I'm going to make enough study time on this rotation.

When I'm there during the day, I don't have time for anything. I've already cut down my pumping to 2 sessions a day, but that still means I'm losing about 45 minutes in that 9 hour day where I could be doing clinical stuff, so I have to get the same amount of work done in less time (3-4 hours of that 9 is meeting/running the list/teaching) which means I need to be even more efficient than my peers.

I'm finding it rather hard to be optimistic about the next six weeks.  This is an absolutely critical rotation to my development as a future physician. Much of the information I already know, I just have to work on my confidence in putting together a plan. It's not that I have massive knowledge deficits - not as huge as I feel like they are anyway - but it's just a matter of putting things together in a coherent and structured manner, and learning the ins and outs of how this unit works.

Today, I'm feeling very, very student-y. Unprepared, unknowledgeable, and almost paralyzed with anxiety about screwing up.

I know I'll get over that feeling, and I'll figure out how to make my studying time work because I always do, but in the meantime, I'm going to just have to remember to breathe.

At least I'm usually able to do that.

Sunday, 7 May 2017

I'm Not Very Good at Plans

So a few days ago I got really excited, thinking I had it all figured out, that I'd do family med and focus on women's health and low-risk obstetrics and just be done in two years and be happy with that and I'd go on my merry way inserting IUDs, doing endometrial biopsies, delivering babies, and giving everyone HPV vaccines.

Then on Friday I was in the OR all day and realized one very important thing: I really like the OR. I got my first inkling of this last year with my IR elective when I learned I like procedures a lot more than I thought I would and my enjoyment has been confirmed repeatedly since.

Friday was my last OR day until late August and that made me very sad. My next rotation is internal medicine, then emerg, then I have family and emerg electives before my surgery core (4 weeks general, 2 weeks gynae onc.)

For my next core, I have to dress up every day. No scrubs. No sneakers. No silly hats and victory laps down the OR racetrack towards PACU.

May eleventh is exactly 1 year from the final day of our program. Graduation will be a couple weeks later, but I really finish med school 1 year from Thursday.

In that final year, I have 3 weeks off for CaRMS interviews, 2 weeks winter break, and six weeks of concept integration. It doesn't feel like very much at all, but it's even less when I consider that I've really got six months to decide what I'm going to do for sure because CaRMS is rushing towards us at lightning speed. This year's somewhat depressing match statistics - 77 OB spots for 113 applicants listing it as first choice - have been released and that's it. Next year, one of those data points will be me.

The 2017s are done clerkship; we're not seeing them around the hospital anymore because they're doing concept integration. Well, they were. I think they are done now, and just finishing their preparation to write their LMCCs.

They graduate on the 25th and then we're the senior medical students.

I really need to have my future figured out pretty soon. The end of medical school is approaching rapidly (I'm sure I'll feel differently around 2am on Wednesday when I still have 6 hours to go before I can leave) and I just feel like I can't decide.

When you compare the first two years of, as an example, Mac's OB residency and the first two years of the family med program back home around half of the rotations are the same. The big difference is that 9 blocks (36 weeks) of the FM residency is community FM, so you're working generally better hours than OB residents for 8 months.

Realistically, a family med residency isn't going to be *that* much easier over the course of those two years. And the last half of an OB/Gyn residency is less school than it is practice with eventually irrelevant training wheels and lower CMPA premiums.

It would be lovely if the answer to my indecision would just fall out of the sky.




Friday, 5 May 2017

Kay's Tips for Being a Good Clerk

So from my accumulated wisdom from the last four months of clerkship, I've learned a handful of things I wish to share. 

1. Carry at least two (functioning!) pens  and a piece of scrap paper at all times. 

2. Watch what your staff does so you can learn how they do things - ESPECIALLY surgeons. You may get looked at like you have two heads for doing something the way you were taught by another staff. Don't take it personally. 

3. Don't take anything personally. 

4. If someone 'corrects' you, even though you are doing something exactly the way you were instructed to do it 24h before, just go with it. Don't argue. Related: if you're told you contaminated yourself and you're 100% positive you didn't, still don't argue. Get a sleeve/new glove/new gown anyway. 

5. Thank people for teaching you. Not everyone will try. 

6. If you need paperwork filled out, let your supervising staff/resident know early on in the day. 

7. Get to know the nurses and other allied health. They almost certainly know more than you do about what you should be doing especially if you're brand new on a service.  

8. Waterproof shoes. 

9. If you feel lightheaded in the OR - and it happens to lots of people! - let the surgeon/resident know, hand off your tools/retractor and step away and sit immediately. Don't try to fight it. Don't risk passing out in the field. For one, it's not good for the patient. Two, no one likes it if the med student creating a mess of paperwork. (I have not passed out, but I nearly did.)

10. If your staff or resident tells you to go eat, rest, or grab a coffee, do so. As in immediately. Don't wait around, don't ask if they're sure. Run for the call room/break room/washroom as fast as your little legs will carry you. 

11. If you're asked if you'd like to go home early, the answer is yes. 


Tuesday, 2 May 2017

Re-evaluating My Options

Five facts that are causing me some stress:
1. I love obstetrics and gynaecology. A lot.
2. I have concerns about the physical toll of an OB/Gyn residency on me and the stress it will place on my family.
3. I will likely not be able to return home for a long time if I do OB/Gyn.
4. I do not greatly enjoy the full scope of family med nearly as much as I like OB/Gyn, but do enjoy some parts that are not part of the OB/Gyn scope (well-baby care, breastfeeding concerns)
5. We all really want to go home.

So I'm looking into the possibility of being a women's health-focused family physician who does low-risk obstetrics including deliveries. As far as I'm aware, there's really only one family doctor on the Island who does deliveries routinely, but I know in Ontario there are multiple family doctor groups that do low-risk obstetrics and women's health.

There is at least one physician on the Island whose practice is primarily women's health, and there's another I'm aware of who receives referrals from other family physicians because she does things like IUD insertions and pessary management. They're also establishing a women's health centre out of one of the hospitals, and last I heard they've been looking for someone who will work there.

I think I'd be satisfied with not having gynae surgery as a part of my practice if I were still able to do obstetrics and women's health as the majority of my practice.

In Ontario, I know it's entirely possible to do that.

I don't know about how achievable that is back home, but if it can happen, I want to make it happen.

It would be the best of both worlds if I could manage pregnant patients through pregnancy, parturition, and postpartum, see their babies for well-baby checks at the same time as postpartum checks, see them for breastfeeding concerns, do contraceptive counselling and IUD insertions, STI screening and management, do initial nonsurgical management of gynae issues like endometriosis, prolapse, and PCOS. Do low-risk OB, primary care gynae, some paeds.

None of that is outside the scope of a family doctor. Most family doctors don't do deliveries nowadays, but it's more a practical consideration - you basically always have to be on call to manage your own patients' deliveries - but that's manageable if it's done as a call group, and I know for a fact that there are family doctors who do that.

I figure, if a family doctor can do primarily emerg, or hospitalist, or geriatrics, or palliative, why can't I do women's and infants health?

If I could go into a family medicine residency being sure that I could make that sort of thing into my future, I would do it in a heartbeat and I don't think I'd regret the fact that I wouldn't be doing surgery.

I love OB/Gyn, but if I could be something between a family doctor and an OB/Gyn, I'll dive in with both feet.

I think I'm going to call the offices of the doctors back home who I know do more women's health-oriented practice and see if I can speak with them, and I think I might try to change my family med elective this summer to be with a women's health focused family doc.

Thinking on this, it's actually feeling like this might be a workable solution, and might be a good way to shape my career the way I want it to be, combine all areas I enjoy, and provide a desperately needed service to my home province.

It would also mean we could go home, potentially as early as next year if I match to that family med program. That is incredibly tempting.

I'd have to leave for a year (possibly) to do a women's health fellowship, but there's also the possibility I could do that in the maritimes, so I could potentially just be gone during the week.

This seems workable, but I need more information so that's my next steps.