Being a medical student

Students, you make us better doctors!

snow-white-mirror

 

As a medical student, I remember a consultant saying to me, “Watch what I do, take away what you like, forget what you don’t. Do that throughout your career and you’ll end up emulating the best of your trainers.” I found this strange, as it encouraged me to scrutinise the way senior doctors behaved. Now, as a consultant, I recognise that whatever I say or do is considered and judged by those I train.

This creates a pressure, to put across the best of myself. And that requires energy. So, if I walk into a clinic room and am told by the nurse that there is a student waiting for me, I may experience a brief “Oh…really?” Many students will have witnessed a slight deflation in the faces of doctors to whom they have been attached for the morning or afternoon – as though to say, “What a pain!” Their presence will change the way I conduct myself. I will have to be mindful of their need to understand and be involved with the consultations (otherwise they will become completely bored). And it will complicate my interaction with patients, should they appear hesitant or show signs of annoyance when I introduce the observer. What would have been a series of two-way interactions turns into into a three way, dual purpse conversation. All of this requires an investment of concentration and effort.

This apparent downside has advantages. Having accepted the fact that I have a student, I will move into a different gear. I become teacher and doctor. My behaviour tends to improve. If I find myself behaving less than perfectly, I will remind myself that the impression I am making is contributing to the development of that young student or doctor. They will either accept or reject my approach, not formally, not such that their impression will be fed back to me, but cumulatively. I do not want them to look back, fours years hence, and say, “Yes I remember seeing a consultant do such and such, and I told myself there and then that I never wanted to be like that with patients.” (We all have examples we can think of, I’m sure!) We only have to look back on our own evolution as students, junior doctors and middle grades, to recognise that the way we behave now is due to an accumulation of different experiences and different judgments. None of us want to display behviours that end up on the discarded pile.

What else does the student bring to the clinic or ward? He or she brings the need for clarity. Their questions have a habit of cutting through any pretence to omniscience that we may have maintained while trying to understand a complicated concept or disease. Just as a fallible maths teacher may crumble in the face of an apparently naive question about geometry from a 10 year old, so a medical student’s simple enquiry about auto-antibodies or cardiac murmurs can reveal the true depth of one’s true understanding. To avoid such discomfiture in the future, you may even go and look it up for first time in ten years. Sometimes, you find yourself explaining a complex situation to the patient and the student simultaneously. This generates a true sense of engagement, and can result in a successful scientific or technical interpretation, understood by both in plain language.

They can also work, quietly, to preserve our humanity, and perhaps such a simple quality as politeness. If I’m running late, it is easy to fall into a pattern of hasty turnarounds and compressed consultations. Any temptation to hurry the patient along will be countered by the knowledge that efficiency tricks and verbal ticks are being observed. I may know the patient has unanswered questions, which I ‘just do not have time’ to address. One look at the student’s face will tell me if I’ve been too hasty. Caught up in the ever-present temptation to hurry, the outsider’s expression serves as a barometer of decency.

Perhaps some doctors, supremely confident in the way they behave, are not influenced by the presence of students. Others may put on a performance, energised by the showmanship that expertise and hierarchy can encourage..although this can result in the patient being excluded from the interaction. It has to be remembered that the axis of primary importance in the room is that between patient and doctor, not doctor and student.

So having students around can be a good thing, for patients. And for senior doctors they are valuable too, as moving mirrors, passing influencers, potent in their ability to reflect back the best and worst of our ingrained medical habits. Saying that, I would not want to be followed by students all hours, all days. Because they require attention, they will necessarily slow down whatever medical process they happen to be observing. Sometimes it is nice just to get on with your own thing, in your own way, even if that does involve falling back into your own bad habits (or catching up on emails). But now and again it does no harm at all for someone to put a mirror in the corner. Sometimes that mirror will speak, and, venturing outside the comfort zone of silence, say ‘I thought you did that really well.’

 

SPOKENcreatspaceCOVER

Advertisements

Fade to green

Faint2

I fainted half a dozen times during my training. It’s a problem that worries quite a few people, so here are some of my fainting tales. They may make you feel better.

I should have known it would be a problem because during GCSE biology I was asked to dissect a cow’s eye. It slipped and rolled under my scalpel, glancing at me as it turned. My teacher asked me if I was alright. Apparently I had gone green. As soon as he said that I began to feel green. I lay my head down on the cool workbench and soon recovered. It was close one.

Then, before applying to med school, I spent a night in the local Casualty department. I watched a junior doctor try to prise a splinter from the hand of a young lady. It was hurting her, and she kept yelping. The doctor got irritated and said the anaesthetic ‘should be working’. He kept digging into her hand, she started to cry, I felt lightheaded, moved my legs to keep the blood flowing…and I was out. It wasn’t the gore, it was the negative emotion – I think. Anyway, they put me on a trolley, checked my blood glucose, and the same doctor told me the only explanation for such low levels was an insulinoma. I got home, looked it up, and for some months assumed there was something unpleasant growing within me.

So to med school, and the post-mortem. I had been really looking forward to this. The Professor of pathology lifted out a series of pre-mobilised organs and held them up for those of us in the viewing gallery to see. I glanced past his gloved hands at the cadaver, glimpsed the head, saw the juices drip off the liver…and down I went. As usual I came around immediately, to be told that when the Professor heard the thump he looked up and called out, ‘Will someone see if she’s alright?’

Then came venesection practise. My partner shakily inserted a needle into one side of my elbow vein and out the other, causing a ‘sixer’ sized haematoma. As it swelled I began to sweat, the edges of my visual field closed in and I immediately sat on the floor with my head between my knees. Another close one. However, come the first day of my third year as a medical student, entering the wards at last after two years of lectures, I did less well. We met the house officer (she seemed so grown up) and were told that it was our job to do the phlebotomy rounds each morning. She assembled a vacutainer set and asked me to roll my sleeve up. Pretending to take blood, she held the needle a centimetre from my skin. My brain said NO WAY, the sweat came on and clunk, I was down. The clunk was the sound of my forehead connecting with the edge of a sink. The rest of the day went fine, but the bruise took a week to settle.

I entered the operating theatre as a student on a vascular surgical firm with great trepidation. For some reason the blood and gore did not affect me as it did some others. I watched a consultant repair a ruptured abdominal aneurysm, observed the blood as it pour off the table into his white rubber boots, saw him curse as he nicked the spleen and was forced to remove it…but the fascination allowed no room for vasovagal syncope.

But I was not cured. For my elective I travelled to Nepal via Delhi.  In a busy Indian market square I asked a cobbler to repair the soles of my shoes. He stuck strips of orange rubber onto them with stringy glue that he applied with a stick. His friend tried to clean out my ears with a cotton bud while I waited, but I pushed him away. I was pleased with the job on the shoes though. Anyway, come the first day on the wards in Kathmandu I was feeling a bit rough, having accidentally swallowed some tap water while shaving two days before. I stood in the breeze of an inadequate fan, watched a cat slink between the legs of a hospital bed and lick some organic fluid from the edge of bucket containing sharps…and there we go! I came to on a bed with ECG stickers on my chest. The Professor, a very serious man, asked me if I had a heart problem. I said no. What really upset me was the group of students and doctors at the foot of the bed peering at the soles of my shoes.

After that there were no more uncontrolled total faints. I came close during a stressful central line insertion as a senior house officer, but I think a hangover predisposed me to it. I slipped to the floor, put my cheek to the plastic tiles, sweating, the wire still sticking out of the patient’s neck, and fought it until a nurse brought a cup of ice cold water. Within minutes I was back on my feet, hands clean, fresh gloves on, ready to finish the job. I don’t think the patient ever knew what was going on.

Since then I have found myself in many faint-prone situations, but I am glad to report that it is no longer a problem. Blood, stress, chaos, suffering…none of it hits my pulse rate or blood pressure. Rest assured, if you are a fainter, it gets better.

 

[This article appeared in The Guardian online]

cover to tweet

Click picture to explore

The needle and the damage done: circumspection

needle

Scrolling through my timeline on Twitter the other day, I saw that a junior doctor had suffered a ‘blood splash’, presumably in the face. This is when a patient’s blood is sprayed or flicked into your mouth or eyes…carrying with it the risk of infection from a blood borne virus such as hepatitis C or HIV (medical staff are immunised to hepatitis B). It made me think back on a similar experience as a junior doctor…a needle stick injury from a patient infected with hepatitis C. I’ll describe what happened in a minute, not because I enjoy telling unpleasant personal stories, but because I think the impact that these ‘avoidable but let’s face it they’re going to happen now again’ accidents have on doctors and nurses should be understood and emphasised. When I looked into the subject I discovered that research had been published on the subject this year, the results of which I will go on to summarise. It seems that the psychological impact of these accidents can be very grave indeed.

*

As soon as I felt the deep sting of the needle as it entered my finger I knew what it meant – potential disaster. I was cutting a space between the ribs of a patient on intensive care, making room for the insertion of a large chest drain. The tissues were tough, and I had to tear at the fibres with my fingers deep under the skin. But the patient was not sedated, and she was feeling it despite the local anaesthetic injection I had administered beforehand. So I did something stupid. I kept one finger in the cut, so as not to lose the track I had struggled to form, and with my other hand I carefully inserted the anaesthetic needle alongside it. In this way I hoped to numb the deeper tissues. I jabbed my own fingertip – ouch…a shock, but not really painful. It was the knowledge that hepatitis C viruses in my patient’s blood could now be running up the veins of my arm and into my bloodstream that caused me to freeze in fear. I withdrew my finger, looked down at my hand, tore off the glove, and squeezed the fingertip until droplets came out. The nurse who had been helping me recognised what had happened, but had nothing to say. I walked over to a sink, washed the blood off, wrapped a waterproof dressing around the tiny wound and went back to the patient. She still needed a chest drain after all. Soon the job was done, and the rest of the nightshift passed without incident. But throughout the small hours I could think only of myself: were there any viruses in the needle? How many would it take to cause a permanent infection? Would I need anti-viral treatment, would it work, could I continue to be a doctor while receiving the famously toxic combination of interferon and ribavirin? Might it fail, would I develop cirrhosis, would I end up in this very hospital, waiting for a transplant? Oh God.

I was distracted by anxiety for weeks, not to a disabling degree…not so as anyone would notice. At six weeks I had a blood test to see if there were detectable levels of virus in me. A week later I attended the occupational health department to get the result. The nurse had not read a Hep C result before, it seemed to me. She looked quizzically at the small piece of paper in front of her, and tilted her head slightly.

‘Err…you have…err…Hepatitis C.’

I nearly fainted. I looked at the report closely, upside-down, and lunged forward,

‘Let me see that!’

I turned the report round and saw that she had misread a < for a >. I had < 50 virus particles per millilitreof blood, not > 50! I was negative! She accepted my interpretation, and was embarrassed. I left the room and walked back to my ward. My skin was cold and wet. I felt fifteen years older.

There were antibody tests at three and six months, and they were negative too. I was not infected. In fact, looking back, knowing more now about the absolute risks, and the cleaning action that plastic gloves perform as a needle passes through them, it was never very likely. But the experience changed me.

*

Professor Ben Green and Emily Griffiths (University of Chester) recently published a paper called ‘Psychiatric consequences of needle stick injury‘ in Occupational Medicine. They administered a depression questionnaire to 17 needle stick injury (NSI) recipients who had been badly affected enough to be referred to a psychiatric clinic. None were actually infected. They compared these results with 125 non-NSI recipients who had been referred for other forms of psychological trauma. The authors hypothesised that NSI caused shorter or less intense periods of psychological morbidity. Their findings included a description that I recognised immediately,

Four of the cases (24%) described an initial period of up to 2 days of acute anxiety, disbelief, tremor and profound sleeplessness consistent with an acute stress reaction.’

Within the (admittedly highly selected) group of 17,

‘Thirteen (76%)…had a diagnosis of adjustment disorder (AD). Four (24%) met the guidelines for post traumatic stress disorder according to ICD-10 diagnoses.’

Other observations included,

‘NSI patients with AD repeatedly said that although accident and emergency staff or occupational health staff had reassured them that the chances of seroconversion were small they focused on the fact that there was still a ‘possibility’ of seroconversion and thus did not feel reassured.

They concluded, among other things, that

‘psychiatric disorders in NSI patients were similar to other trauma-related psychiatric illness in severity, but while they last for 9 months on average, this was not as long as other psychiatric trauma patients. Psychiatric illness following NSIs had major impacts on work attendance, family relationships and sexual health.’

*

These individuals were at the worse end of the spectrum, and the conclusions reached in this paper do not apply to all NSI recipients. I wonder if there is a more subtle effect on those who do not end up being seen by a psychiatrist – a heightened, and more general, sense of self-preservation. My own experience brought it home to me that while my career would involve seeing hundreds or thousands of patients who might carry serious or incurable infections, there was only one of me. I resolved to do everything I could to protect myself…not to a paranoid degree, but by applying a greater sense of caution. So, instead of plunging into the next cardiac arrest situation without a care for the bodily fluids that were leaking onto the patient’s chest or bed, I held back until my gloves were safely on. I know that’s what you’re supposed to do anyway, but in real life people don’t. They rush to save the patient. When I saw a woman collapse during a night out in Soho I ran up to her, checked for a pulse, but did not contemplate performing mouth-to-mouth resuscitation without a mask. I felt selfish, but I could not face the prospect of waiting for more blood test results. (Mouth to mouth is out of fashion now anyway – and fortunately, she was breathing.) Beyond the arena of infection, I became less inclined to make sacrifices that might affect my health or put me at risk of making mistakes; swapping into crazy sequences of night and day shifts as a favour for colleagues, covering extra clinics when dog-tired…sensible behaviour, in no way abnormal, but a change. The damage done.

The Needle and the Damage Done is a song by Neil Young (Harvest, 1972)

[an adapted version of this article appeared in The Guardian online]

cover to tweet