A passport to better service?

Conversation in the Boots pharmacy near the hospital:
me: Hello, one bottle of Movicol liquid* please
pharmacy man [patronisingly]: No, Movicol is a powder that comes in sachets. It's not a liquid.
me: Yes it is, it comes in bottles
pharmacy man: No, it doesn't
me: Yes....
pharmacy man: No, we don't have it.

He was patronising in the extreme, and seemingly isn't used to patients/customers who actually know what they're talking about. Or just assumes that patients/customers don't know what they're talking about.
I've been taking this medication for a while, I know exactly what it is, I don't talk rubbish. I resented the implication that I do.

I found myself regretting that my NHS hospital badge was in my bag and not visibly about my person, as it had been half an hour earlier. It may say medical student, and not 97% doctor, but I imagine it would make it clearer that I do know what I'm talking about. I am so intrigued as to how things might have gone differently if I had been wearing it - I think the conversation would have been very different.
Having said that, I hate the idea that a hospital badge could have been my passport to good service and pleasant treatment. No patient should be assumed to be stupid, and made to feel so, and have to argue to get their valid request across, whether they have a hospital badge or not.

I don't want to be treated better than other people by virtue of my education or profession, I'd rather everyone was treated better.

I really hope after I left he went away and looked up his formulary, so that next time someone asks, he knows that Movicol liquid does exist, and isn't rude. Though I just hope he isn't rude regardless.

*Movicol liquid is a bottle of mild laxative that is diluted and drunk. It's better than the sachets because from a big bottle the dosage can be altered on a daily basis as required, whereas sachets come in a set dosage size. The liquid hasn't been available for very long, and I found out about it from an advert in the BMJ - is that more proof that I know what I'm talking about?!
Direct-to-consumer advertising for prescription medications is not allowed in the UK, as far as I understand (although Movicol is available over the counter in pharmacies as well as on prescription), so the BMJ advert is aimed at prescribers. But that doesn't stop patients like me from seeing it!

Attempting to Access Adult Asperger Support Services Part 1

The Family Cracking-up-and-significant-breakdown Prevention Project (in family, I don't include my father - he's far too in his own head and own world to notice anything going on around him that could cause cracking up. That sounds like an insult; it's not, it's just how things are): so far, so good.

Whilst on an employability training scheme year, run by a special school, my sister spent a few nights at a residential independence skills training organisation, and that organisation will very happily take her again, on a regular basis. No prior assessments or referrals required. Hooray!

But this is only funded if she has a social worker. She last had a social worker under Children's Services. However, being a disabled and vulnerable child with a learning difficulty, requiring a social worker, seemingly does not mean one will become a disabled and vulnerable adult, with a learning difficulty, requiring a social worker. So she doesn't have one, and my next task is to get her one.

Once we've got her one, accessing this regular residential service should be easy, as the council's social services accept that independence training saves them a lot of money when the young person comes to move to a more independent place of living. A more independent person (as a result of independence training) requires less support, saving the council money.

So Part 2 will be obtaining a social work assessment. No idea how easy that will be or how long it will take.

Family wishes, difficulties and challenges

My mother has had an objectively more difficult life than anyone I've ever known. I wish she could accept that finding her difficult life difficult, or finding my very challenging sister* very challenging, does not make her a failure, and does not mean she has to tell the world she can't cope (she does cope, but sometimes she's pushed to the edge of coping-ability). I wish I had a way to make her know this.

This week I'm going to call up various agencies - I wish I could do more but even doing the small things is helpful, I hope. I'm calling because it's easier for me than for my mum to hear "No, we can't/won't help you / budget cuts / no space / we help people with learning disabilities, not "high-functioning" like Asperger's / we can't help people who are in employment"... those replies don't directly make my life more difficult, they're not as much a kick to the stomach when you're down as they could be for a primary cater facing challenging behaviour.

I so much hope I don't get those replies. Otherwise, well, it's convenient I'm living nearer family for my foundation programme years, because respite care (that I hope to help provide) is so essential. Especially when that care is mostly emotional.

*She has Asperger syndrome (an autistic spectrum disorder, at the high-funtioning end) amongst other diagnoses, so can have challenging behaviour.

Thank goodness for that

I passed my exams, I am deemed safe enough and competent enough to be an almost-doctor. But of course I am not yet a doctor, because I have the first-attempt re-take still to go in five weeks' time.

I've just passed four big exams, which should be a celebration, but all I can feel is relief: thank God for that, thank God that's over, thank God I don't have to do that again. Oh and hooray for me as well? Maybe. Not so sure about that bit.

The full extent of my celebrating has been having a cream tea yesterday, and a fancy readymeal from Waitrose. All of my friends who actually are now doctors (no re-takes for them) must have gone big on the celebrations yesterday, but they'll just have to join me in my celebrations come July. Or they won't because when I get my results, we'll all be on holiday.... but July can be my big party.

The only extra benefit of these results is that it gives more weight to the argument that my failure in January was the medical school's fault, not mine. Their "mishap" did throw me off, and now that I'm over that, nothing can throw me now.

There's very little to stop me now - four weeks of exam preparation, which is all re-learning things that I already know, and then time to ace the re-take, which I fully intend to. Medical school in its simplest form is five years, and when I started I was told it costs £250,000 to train a doctor (it's probably a fair bit more now). So after we passed each year, there were various claims of "I'm now two fifths a doctor!" or my favourite "I am now worth £100,000" (after passing two years).
So now that I've done 4 years and 34 weeks (out of 40) of a 5 year course (let's not include my extra years, for simplicity's sake - they weren't strictly medicine), that makes me 97% a doctor. And 97% of quarter of a million is £242,500 - that's what I'm worth! That's got to be something to celebrate... it's too much money for anyone to want to waste (though it wouldn't be the first time) so I am going to ace the June exam. With bells on.

Watch this space for the mega-big-time-party-celebration in July. In the meantime, thank goodness for that.

The biggest and finalest final

If it weren't for the pesky re-take I have to do in a few weeks, today could have been my last exam of medical school. It was the biggest, most comprehensive, and most terrifying exam of them all - the Medicine OSCE* (incorporating elderly care and mental health and anything at all that's not surgery, obstetrics, gynaecology and paediatrics). The one that if you fail, you can't work as a doctor for another year.

Today I wore the shirt that I wore to my interview to get into medical school 7 1/2 years ago, in 2004. It felt appropriately full circle. And if it was lucky then, it could be lucky now (though it was slightly on the tighter side now than then!). 

 

* OSCE = observed structured clinical examination. Big scary practical exam where you pretend to be a doctor, to prove you can. In a too short space of time, repeated many times over for half a day. The stuff of nightmares.

The loveliest statistician (i.e. geek)

The other day I had an exam in the morning, it was two hours long and a bit stressful. After joining the other half for lunch (amazing chilli nachos), I spent the afternoon with a good friend. We spent about four hours working on her medical dissertation project, which needed some statistics. I have the statistics programme, SPSS, went to lots of statistics courses last year (which I STILL have yet to be reimbursed for) and my dissertation last year was basically all statistics, which I had to teach myself and do myself, so I can sort of hold my own when it comes to medical statistics.

Although it took a fair bit of brain-effort to recall everything I’d forgotten over the past year, this came in very useful for my friend. Her project has gone from having some percentages that look quite nice, to having Chi-squared for trend with a p value less than 0.001 – to anyone who knows research, that’s gone from “somebody found that the intervention probably changed things a bit” to “they found that changes resulting from the intervention were highly significant, with a less than one in 1000 possibility that they were just caused by chance, therefore these interventions are good and everyone should adopt them”. We also added in some nice standard deviations because ranges should be left behind at Maths GCSE.

Surprisingly successful for a post-exam afternoon, where the temptation to just slump is strong. Instead we spent hours fiddling with SPSS, transferring her data from Excel to SPSS, making new data files, fiddling until we found some results that meant something, were the right type of statistics, and were reproducible for the rest of her data. But the worst of it is: I really enjoyed it. I feel I shouldn’t admit to this. This is statistics after all – possibly the most boring thing I’ve ever had to learn about throughout both my medical and genetics degrees. It is the realm of geeks of the dullest kind. I’m not going to deny my geekness, I did do a genetics degree after all, but statistics geekery is a few steps too far; I am not that boring! Learning about stats is mindnumbing, but actually implementing it, playing with SPSS sot that you get something shiny and publishable – I’ll be honest, that is fun. It’s experimentation, with useful results.

I feel I should embrace my inner stats-geek, and have a potential idea: I’ll become a FREElance statistician, as a junior doctor. Here’s the deal – you (consultant, researcher, clinician, nurse specialist, whoever) have a research project that you hope will show something exciting, and you’ll want to tell the world about it. I am an academic junior doctor, and I will do your boring statistics for you. Give me your data, and I’ll give you the shiny publishable results. If you ask nicely, I’ll even write your results up for you (I like a nicely displayed table). I will not write anything else – your introduction and discussion and all the wordy bits are yours alone (I hate writing). I’ll write the paragraph on how I analysed the results, I’d have to really. And the best bit: I’ll do all this for free. All I require is that you put my name on your publication or conference abstract, after all, I will have contributed to it.

And if you’re really organised, I can discuss your data collection methods with you before you start, to ensure you’re collecting the best data to get the best results.

Do we have a deal? What’s not to like?! I would love to know if this would actually work in reality. If you (non-existent readers) know anyone who needs some medical stats… Trying To Be A Medical Student is here to help – you know where to find me.

Win-win situation: the researchers who don’t have time or understanding or patience or SPSS get their statistics done for them, I get more research experience, and I get published, which can only help my academic career. And will add something non-gynaecology-related to my CV, and since that’s not an area I plan to go into (never going to be a surgeon), that would be useful.

Here’s to embracing the inner geek. And to helping friends out.

Saving the world, one starfish at a time (or not)

Before I start, I am under no illusions - I am not saving the world!

This morning, as I went out early, I found a starfish on the pavement, just by the doorstep. A real starfish - the photo is at the bottom. It looked wet and it seemed reasonable to think it might still be alive. I was amazed and wondered if the storm or rain last night had really been bad enough to pick up a starfish and carry it the 500m+ it would need to travel.... and rushed off to my appointment.
When I got back half an hour later, it was still there, so I took photos, and went to tell other half about it. He very sensibly pointed out that it was probably dropped there by a seagull (not as exciting as the idea of wether-induced flying starfish, but far more plausible). I dragged him out of bed and we hatched a plan to take it back to its home and put it in the sea.

I'll explain here that there is a sort of parable by which I'd like to live my life, commonly known as "the starfish story" or The Star Thrower, written by Loren Eiseley in 1969. It's been re-told many times in different ways, and I heard about it from my utterly uninspiring headteacher, who managed to inspire me with this - I can't remember anything else remotely inspirational or even interesting that he ever said.
The version I remember I think of as having a small boy as the thrower, others have an old man or a girl. The beach is covered in starfish which have been washed up after a storm. Someone, let's say a small boy, is walking along the beach, throwing starfish back into the sea, one by one. Someone else, I think an old man, walks up to him and says "why are you doing this? there are thousands of starfish here, you can't possibly make a difference". The boy picks up another starfish and throws it, saying "I made a difference to that one".

It's such a simple, beautiful story, and although I don't think of it often, it's stayed with me over the years. I understood the message to be: you don't have to change the whole world, but you can make a difference to someone, or even a few people. Even if you make a difference only to a few, you have still made a difference, you can still change lives.

Others perceive it as meaning you should do what you believe in no matter the criticism. On looking it up just now, some versions have the old man deciding to join the boy in throwing the starfish, and more and more people join in, ending with the rather twee "all the starfish were saved" (personally I don't think saving all the starfish is the point, I think the point is that it is always worth making a difference, even if you can't make a difference for everyone; you can't save the world - saving all the starfish kind of is saving the world, and feels unrealistic). In that version, the message can be that you achieve something if you all work together, or if you can persuade everyone that it is worth making a difference.

I think this story is one of the things that spurs me on to do what I do, or what I'm going to do, be it medicine, volunteering with seriously ill children (more on that another time), campaigning, volunteering in schools... Each patient in my medical career could be a potential starfish. Not that they've all come to me to be saved, but that even if I can't do everything, I can still make a difference. To remind me of this, I have two beautiful pictures of starfish - one a birthday card from the other half some years ago, and one a sparkly postcard I bought last year while presenting my work at a conference abroad. I want to frame them both.

Back to this morning: given that this story really means something to me, I thought it would be a great idea to live in out (on a minute scale) myself, and take our doorstep starfish back to the sea. I didn't want to do it on my own - I thought I might need help (my intention was to carry it on a baking tray, I thought that way it might not dry out too much), I wanted it to document the starfish saving adventure photographically, and also I thought I would feel less silly and look less nuts if there were two of us poking and picking up a starfish and carrying it along. So I woke up the other half, got back in bed for a bit, waited for him to properly wake up and get dressed and got some plastic bags and an oven tray together, took other half outside with me.... only to find the starfish had gone. I don't know what happened. Maybe another seagull came along and thought it looked tasty. Maybe the first seagull wanted another go. Maybe some other people had the same idea and got there first, and the starfish is now happily floating away.... I'll never know. But I'm kind of kicking myself for not getting straight back outside and doing it myself. Specially if the seagulls got it.

I don't even know if it was still alive in the first place. But I'm still a bit sad about it - next time I'll seize the opportunity to throw a starfish when I see it, not half an hour later.

However, the positives: I saw a starfish! I never even knew they lived in this country.
In this time of considerable stress about exams, whether I'm good enough to pass, whether I'm good enough to be a doctor, whether I even really want to be a junior doctor with the stress and responsibility and total lack of confidence in my non-existent abilities that that involves, it was nice to be reminded of a reason why I came here in the first place - to make a difference, even if only to a few starfish out of thousands. That I can be that difference, and that it's worth it even if you can't save the world.

To have a real starfish to remind my of all this, to make me keep going - maybe that starfish was on my doorstep for a reason. I don't believe in fate - that would have been a nice explanation. But sometimes things happen for a reason, and today's starfish could have been there to rejuvenate and encourage me, to remind me to keep going. So I will.

[I realise this post could give away where I am, and therefore which medical school I'm at. And this is supposedly an anonymous blog. Please note I am not necessarily at home, or not necessarily at the place where I study - I might have gone away somewhere. Or be staying with family. You never know - make no assumptions.]

Dignity

Today I was writing notes on practical procedures, for practical exam revision. Specifically, I was writing about male catheterisation, which is a complicated process, so I made a nice step-by-step flow-chart.

One of my flow-chart boxes said simply "expose patient, maintain dignity". That's all it needed to say for th purposes of my notes, but it struck me how unrealistic that is; if it were as easy as just writing it in a flow-chart box and it were magically done, all hospital patients would be wonderfully dignified. Even whilst being catheterised (I've been catheterised; it is an unpleasant and rather undignified procedure, and I know that even without full recollection if it - I was still woozy from the general anaesthetic).

I love the idea that one could just mentally note "maintain dignity" and that would be all it took. It's so far from the truth. In all honesty, I don't even know how to maintain someone's dignity, particularly when they're being catheterised. I find it especially difficult with old people, more so when dementia is a feature (that's another post for another time). Being professional I'm sure helps, but there's more to it than that.

And I certainly don't know how to maintain it since when going over my notes I discovered I had forgotten that vital step "cover patient with sterile drape" - sheet with small hole for penis to protrude onto sterile field is going to provide somewhat more dignity than general genital exposure. Woops. The sheet is in the catheter pack, so it's unlikely I'd forget when I'm actually trying to do it.

I also forgot to mention the essential step of "reposition foreskin" - if the foreskin is retracted for a long period of time, scarring and serious damage can result. I should be able to do this in practice; the first time I observed a male catheterisation, the doctor had forgotten to do this and I reminded them, so I should be ok (as should the patient's penis).

For now, all my brief notes can really include is the simple "maintain dignity", but at least it will serve as a reminder that in practice, this is always something to consider. It will remind me to think about the patient's dignity, even if achieving it is a task that seems mysterious, difficult, and at times, impossible.

Medicine is funny, bodies are strange.... aka I know nothing

I took myself to the doctor today, had been putting it off for a while, but now I had a weird mouth pain. It had been there a few days, under my tongue, on one side. I'd decided it had something to do with a salivary gland (there's not really anything else under the tongue that's likely to cause pain, I thought), either a stone, or it had got infected.

I hadn’t found anything under my tongue, and neither could the doctor. He proded my neck a bit, which was surprisingly painful, and concluded I had a swollen lymph node, which could be causing the under-tongue pain. I hadn't noticed it, and still can't really feel it now if I palpate my neck - don't come to me with your swollen lymph nodes, people. I may not notice them.

Just as he was about to move on from the mouth/tongue/neck, he had a quick glance at my throat, just to check. "Aha! That's what it is!" he proclaimed - he might as well have shouted "BINGO!" He had found an aphthous ulcer (a common mouth ulcer) on the corner-roof of my mouth. He seemed very impressed at how big it was, and told me to go and have a look in the mirror when I got home. I duly obeyed, and he was right - it's big, white, and very obvious. It looks like something out of a medical textbook, near the uvula (dangly bit in the middle) and very obvious.

But here's the bit I find weird: it doesn't feel anything like a mouth ulcer. I've had plenty in my time. And they've all been really, really sore and very easy to locate; the pain lets you know precisely where they are. I'm given to understand that that's what mouth ulcers feel like for everyone, no?

Not this one. It's not really sore at all, not in the way that I could point a finger at it, rather that I can only wave a hand around the left part of my face and neck and say "it hurts in this general direction", yet clearly it's the same disease process and tissue breakdown. This isn't to say it's not painful, it's just differently painful. Though it got more painful after I'd seen it and knew what it was, silly brain!

So I'm really intrigued as to why the difference, and wonder whether the back of the mouth has some kind of different nerve innervation. I wish I knew more than that.

But at least I've learnt: don't make assumptions about one's own health problems, don't jump to conclusions, and aphthous ulcers do not always present with a typical history. For medics out there - if you have a patient presenting with a vague neck or mouth pain, check the back of their mouth and their throat. Even if the pain doesn't sound like it's coming from there.

Learning point - I need to improve my neck palpation and ability to detect swollen lymph nodes.

Overall, a productive learning experience!