Another new beginning

Things have not been going very well of late.

Mostly it has just been my own personal issues that unfortuantely do have the ability to get me down and out.

Needless to say, the Musculo test on Friday was atrocious. Not only was the work difficult and volumous, but I could not concentrate or focus for the life of me. It had never before been that bad. Turns out the test was so difficult that even those who could concentrate were guessing almost as much as I was.

My only real consolation is that we will still write clinical in July, and even if the examination at the end of the year goes poorly, I can write the supp.

Today things looked up a bit. I started on my Interanl Medicine rotation. My clinical group and I were quite nervous. Physicians are notorious for being egotististical (-testicle!) and very intimidating.

Our registrar is fortunately quite nice. He is not a push-over and still very intimidating, but he does have a good focus on teaching.

He gave us an excellent tutorial on ECGs today. MUCH more understandable than our classes last year. We didn’t have much ward work so we got the afternoon off – and I ended up studying. There is SO much to know. I have tried to learn as much as possible of last year’s cardio work.

Right now I feel quite good – as if I could do anything. Cook, learn to speak French, be a good student… So I’m trying to take advantage of that without burning out.

I do not want to get over-excited, but I think that perhaps I will enjoy this rotation. I sure am going to try.

Rearranging the Syllabus (Mentally [Again])

As a student – any kind of student – one’s favourite academic activity is to criticise. Your syllabus, modules and lecturers are all weighed, measured and found wanting.

I am going to take a wild guess and say that of all courses offered the world over, medicine is the one that varies the most from institution to institution. What’s more, medical syllabi are constantly changing. To the best of my knowledge, my own university has undergone two major syllabus-revisions in the past fifteen to twenty years.

www.lv-staff.francisparker.org

So we spend a great deal of time discussing the shortcomings of our course and how it should be changed once more.

Lord, they should just put us in charge already.

A while ago The Boy suggested we have a first year course in medical terminology, because his Alma Mater offered it and it supposedly worked. The Boy is coincidentally not in the business of healthcare, but about half of his family is.

I admit, I scoffed at him and his idea. I think it is a stupid idea. We all know that the crème de la crème comes to study our course and they should be enthusiastic and eager to learn. When I was a first year and I didn’t understand a term, I used my meagre understanding of Latin combined with my common sense to figure it out. And if that didn’t help there was always medical dictionaries and Google. Our course is full enough (and long enough) as it is, we really do not need another useless subject crammed into our six years here.

But then Friend in my clinical group suggested it too. And he is a medical student, so I could not exactly scoff at him. Turns out a whole bunch of students on our campus would have welcomed such a module in their first year. So much for enthusiasm and the cat’s whiskers and all that.

It set me thinking though. While we do have an awful lot of work crammed into a long six years, much is left to be desired for the optimal management of said time.

For example, in our first year here we do a module called “Personal and Professional Development”. It is much like South African Life Orientation or USA Citizenship Class. It teaches things like introduction to ethics (despite the fact that we do a full course of medical ethics in our fifth year), and some things on well-being and alcohol and what not. To be honest I don’t remember most of it and I actually did attend those classes.

Professionalism should be something that is fostered in the clinical environment by consultants – you should not try to foster it theoretically. Oh yes, we also did some psychological developmental stages which nobody remembers because it was taught late on a Friday. So perhaps medical terminology would be a better thing to teach in those timeslots.

Still on first year courses, we also did a module on Biostatistics. We all hated it and performed poorly in it. This year I learned that our faculty also experiences problems with said module. It is offered by another faculty, which always presents a ton of problems. Furthermore it quite possible that year in and year out, students perform poorly because it fails to be relevant to their field and there are obviously reasons they chose to study medicine as opposed to Mathematical Statistics.

www.sarkisian.net

The hope is now that a prospective centre for Evidence Based Medicine, set to be implemented in our faculty, will take over the teaching of statistics, but in a manner that is relevant to the health sciences. It is still a long time to go, but it will certainly be a more beneficial venture.

The teaching of a third African language is a noble plan of our faculty. It is essential for a doctor in any community to be able to communicate with his patients, and in a country with ELEVEN official languages, this offers a unique challenge.

In my first year we were given a six week crash course in isiXhosa. We were given a thick book of terms and the tests were of the nature that you could pass without really having studied. For example, Match the Columns. If you know that “ntloko” means “head” and one of the options is “My head hurts”, it is quite easy to match the column.  You don’t really need to know the translation for the rest of the sentence.

Of course the next year they tried making the test more challenging, but that also was not fair because it was still a six-week crash-course.

The latest movement in our faculty – which is truly praiseworthy – is an initiative to make this Xhosa Program one of vertical implementation. In other words, teaching the language continuously throughout the course; making it an outcome for each module so to speak. I am more likely to learn to speak the language at a grassroots level if my clinical logbook includes “basic consultation in Xhosa”.

At my level – doing clinical work – you start realising that you have some serious shortcomings and that it is largely your own fault.

Our theoretical modules are “integrated”. In other words, we do anatomy, physiology, histology, pathology, microbiology, virology, pharmacology (etcetcetc) of one system all in one module.

It is a great idea. The catch however is that some sections may only add up to about five marks in the test and exam. Paediatrics, Microbiology and Pharms are classic examples of this. And of course if you are a busy medical student, you are not going to study eighty pages of memory-intensive stuff for a measly five marks.

So you spot and you pass your exams knowing nothing about, say, the pharmacology and then you get to hospital and your consultant looks at you and says, “Doctor! Your patient is going to die; what do you prescribe?” And you stand with a mouth full of teeth. Nice.

While we were on our Paeds rotation, we decided that we needed a separate Paediatrics Theoretical Module. We had already taken all of our paeds notes from our files and combined them in a separate file. A theoretical module wouldn’t require additional available time, it would simply require rearranging time.

The same goes for pharmacology. We have a pharmacology module at the end of our first year, but that is forgotten long before you enter the clinical arena. Fortunately it seems that another module will soon be implemented for our fifth year.

It is very difficult to educate young people to the level of being medical doctors. The syllabus should evolve constantly. But like I said, just put us in charge already.

Neurosciences 371: The first dissection

South African medical students are very fortunate in that we always have access to cadavers for dissection. Many western countries, as I have been told, simply don’t have these available to medical students.

My class started dissecting in September 2009. The new syllabus is all about integration, so where in the past curricula students spent about a year almost exclusively dissecting, we now have dissection at the beginning of most bodily systems. We have now dissected just about everything except the head/brain/spine and the musculoskeletal system.

Today we started with Neuro-dissection. At this point I should mention that dissection has never really been a problem for me – so much so that that bothered me. I couldn’t equate the body lying on the table with that of a human. It seemed to be only a shell, which I suppose it really is. In my culture, at least.

Cadavers are covered in large sections of cloth, doused in formalin. So while you are dissecting the abdomen, the chest, head and legs remain covered. Firstly this prevents the body from drying out too much (a cadaver is very very valuable and we only have a new intake once a year), but I think it also serves to provide some dignity.

In today’s dissection, we needed to make incisons (to the bone) from the nasion through the bregma right to the opisto cranion. Then another incision from just above the ear, through the bregma to the other ear. We then had to reflect the all the layers of the scalp to bear the skull. I tried finding a nice picture but there were none, so this is an illustration of the different landmarks so you can get an idea of the area of dissection. It is from “Applied Anatomy: the Construction of the Human Body“, by Gwilym G. Davis:

Landmarks of the Skull

This was more difficult than any of the other dissections. Not because of technical difficulty, but because there was no way of denying that our cadaver was once alive. We have just recently had the new intake, so our cadaver is practically untouched, save for the second years who have started their thoracic dissections.

At one point I needed to lift his head for my friend to be able to extend the cut to the occipital protuberance, and as I did my hand rested against his ear. And cold and stiffened as the rest of the body may be, his ear was soft, elastic. It felt akin to what one might feel when caressing the ear of a lover.

On a more positive note, I got to cut a little today. Last year I was, as mentioned before, not very good with class attendance. The times that I was at dissection, I was afraid of making a fool of myself and so I did not demand my fair share of cutting. And nobody is really going to offer it to you if you don’t demand it.

In the world of young medical students, experience is a most prized possession.

I was beginning to worry that I would never know what kind of pressure is necessary to reach bone or viscera. Skin is actually very thin, do you know that? And there is really not that much space between our skulls and the outer layer of skin.

Now, if you’ll excuse me… I need to get rid of this formalin smell.

Le Document pour MB.ChB.II

The inspiration for this document came during my second year while studying for an end-of-block test. At the same time, the then-first years were studying for Pathology, aided by “Le Document”. [If you are a Tygerberg Medical student and you don’t know Le Document, I really pity you.] Anyway, somewhere in this time period I looked at a fellow second year, threw my hands in the air rather dramatically and exclaimed, “I wish I had a Le Document for Second Year!”

As you read this document, you will notice that it is markedly different to the one you used during your first year.

1. It is not focussed on a single module – because the point of your second year is to have a more integrated view on the human body and medical practise. Your patients will not present to you as a system, but as a body (even if you are a super-super-specialist).
2. It is not in Question-Answer format – because that was for first years. In your second year you will often find that you are required to answer things you didn’t even know were being asked.
3. It is application-centred – because this year, you will be swamped by theory; you really don’t need any more

Thus follows some good advice (well, I think it is good advice) and some fun-to-know information. Most of it is subjective, but acquired from a torturous second-year. Much of it you may only truly enjoy by the middle or even the end of your year. Either way:

Enjoy!

Weight loss in your second year

Some of you may be lucky enough to lose weight this year. While it may be attributed to the demise of First Year syndrome or, for a few unluckies, an endocrine disorder (think hyperthyroidism), it could simply be an indication that you don’t have time to eat anymore. If the weight loss is unwanted, eating will be a suitable remedy. Eating is important. If this fails, you may want to visit your GP (but not the third year student who wants to practise drawing bloods on you).

Weight gain in your second year

Others will find that the pounds don’t in fact melt away. The Talley-O’Connor may tell you something like “You are eating too much” or “you have an endocrine disease” [it’s always an endocrine disease!]… well, you might just have Second Year syndrome. This is much the same as First Year syndrome, except that it comes as a complete surprise. Like lung cancer in a non-smoker. It happens.

“Second Year Syndrome: It’s like first years’ syndrome, but with added madness.”

Andipatin-G2-Syndrome

This syndrome, which usually manifests during troublesome blocks such as Digestive System, is characterised by storming into res, ensuring that no member of the opposite sex are in the vicinity, and promptly getting undressed. Hot weather and stressful weeks contribute to the occurrence of this behaviour. Requires no treatment, but coffee-breaks and mutual support are curative.

Five-hour coffee-breaks

These are best appreciated in the week preceding a major test or exam. They start as half-hour study breaks and involve the progressive increase in shared midnight snacks. Conversation may drift from academic stressors, family life, babies, the opposite sex or just plain sex, with little but some variation between genders. Like any drug it can do a tremendous amount of good within the right context. Not recommended for students who have not studied at all by the second day before the test.

Broodiness

A common occurence in female Tygerberg students. Remits when ignored.

Symptoms-of-whatever-I-am-studying syndrome

More common than initially anticipated. With the increase in knowledge of the human body and the many things that can break it, students may start experiencing symptoms of the disease which they are studying. Know that while it is normal, excessive belief in this experience may be damaging to your health (and your medical aid). It is particularly recommended that male students gain control of this condition before commencing the Reproductive module.

Skin de-pigmentation

A completely normal side-effect of above-normal studying.

Sleep

Get some. Try to sleep in at least once over a weekend. Your body will love you for it.

An “uitstel”

a.k.a, deferred exam. These are dangerous and lead to studying on Christmas Eve, Christmas Day and New Year’s Eve. Only opt for an uitstel if you/your wife is giving birth or you have a once-in-a-lifetime opportunity.

Dropping of marks

Students may find that their performance is markedly reduced from MB.ChB I to II. Many believe that first year in fact makes one stupid. Second year thus requires the re-learning of study methods. Attendance of class helps a great deal in passing, particularly if one desires above-average marks. Textbooks, if time and money permit, are of great value and should be utilised.

A Fake Sick-Test

Notoriously under-reported with the only major side-effect being guilt, and only in certain students.

The Urogenital System

In this module it is quite alright to feel violated. If you have never read a Mills&Boons, do yourself a favour and read Chapter 55 in Clinical Gynaecology (textbook).

Some sound advice: The Urogenital Textbook, sold by Faculty, costs R200 and one book contains both an Afrikaans and English section. If money is tight and you don’t consider books to have feelings, find a friend and split the money and the book. If you tell anyone I said that I will deny it vehemently.

Psychiatric symptoms

A great many neurological and psychiatric symptoms may appear during this year. Considering the circumstances, some of them may be described as variations of normal. Do seek help when they become unmanageable. If done in time, major loss of function can be prevented.

“Making Sense of ECGs” by Houghton and Gray

The book that saved my ass. If ECGs don’t come naturally to you, this is definitely one to consider.

Homeostasis

Not just for your body. Maintain this in your social and emotional life as well. Students are often tempted to study eighteen hours a day and reach the end of the year with virtually no life-experience. Never underestimate the value of a good movie, a glass of wine, a trip to the beach or a game of touchies.

Reproductive System

An interesting module for most. The little swimmers don’t know your plans for the future though, or your age. And “chai-vees” don’t care. If abstinence is not your thing… Use protection.

Confused Circadian Rhythm

What happens when eating and sleeping patterns go awry. Normal from this year forward. Survival rate is excellent, but morbidity is high if not reset when possible.

Off-weekends

The lucky break you get when you write an end-of-module test on a Friday. Find out what works best and then use those two and a half days as though it is the last off weekend you will have in the next four to six weeks. Which it is.

Hypo- and hyper involvement

In keeping with the old adage, too much of anything is never good. Either of the above can negatively impact one’s CV, life-experience, relationships and health.

Syndrome [e]X[am]

• Tachypnoea
• Tachycardia
• Nausea
• Insomnia/hypersomnia
• Anorexia
• Cold sweats

But most importantly:

Rememeber that nothing needs to be as bad as people say. It is only as bad as you make it. Enjoy your second year – it (hopefully) only happens once.

Studying for exams: Reproductive System

Today I studied for my Reproductive System examination. Yes, I am trying very hard to take this studying-thing seriously.

The more I study this system, the more I am scared of having children one day. Nevermind that, the more I fear my Obstetrics rotation which will happen next year. That is a bad thing, since I would really like to be an OBGYN one day.

Take episiotomies, for example. An episiotomy is an incision through the perineal muscles for delivery of the foetus. To make it clearer: you cut through the muscles between the patient’s introitus and anus… I do think that hurts. I think it hurts the doctor almost just as much.

The general rule in any medical set up is that you have to stitch that which you cut. Sewing up an episiotomy means sewing three separate layers. Sounds to me like a huge needle-prick risk.

Did you know that Trophoblastic Disease can present much the same way as pregnancy? An enlarged uterus and sometimes even a positive HCG-test (Human Chorionic Gonadotrophin is the hormone utilised in home prognostics).

If an expectant mother is certain of her last period, you can work out the baby’s due-date relatively well by saying:

[(Date of last period) + 7 days] – 3 months

Then there are even formulae for figuring out how far along a pregnancy is if you’re not sure that Mum is right about her dates. Pretty cool.

I used to cringe when people spoke of the “miracle of life”. After reading my whole textbook today I am inclined to agree – it is a bloody miracle that this planet is over-populated as it is. There are so many things that can go wrong during conception, pregnancy and labour.

Goodness. If you are lucky, the baby has no genetic abnormalities. If you are lucky, the foetus grows well and the placenta stays well intact and does it job. THEN baby’s shoulder must be sure not to get stuck anywhere on the way down.

There is a chapter in the textbook that made me cry – about “destructive procedures”. These are procedures that used to be done to deliver a dead foetus vaginally. The chapter is there for “historic relevance” since these procedures are supposedly now considered inhumane and no longer performed. But to give you an idea of the kind of methods that used to be employed, they fall under headings such as craniotomy (perforation of the foetal skull), decapitation and cleidotomy (trans-section of the clavicles).

Imagine having to perform that. Imagine being the mother! I know the foetus would be dead already, but still… apparently when these procedures were indicated, the doctor would induce temporary amnesia so the emotional trauma could be reduced to the mother.

Something which I find really cool is that we are even taught how to deal with our future patients.

A story: I developed a fever at 24 hours after birth. The doctors were very worried, ordered numerous tests and put me in the neonatal ICU. At some point, my mother asked the paediatrician when she could see me. He responded, “Before Christmas.” I was a January baby. My mother cried (I was her firstborn), and when her OBGYN heard what happened he ordered that the incubator be brought to my mom’s room and that a neonatal nurse stay there with her. Needless to say, the OBGYN is still a hero in my mother’s eyes, and the paediatrician is considered a terrible doctor.

I admit that I don’t have nice thoughts about a doctor that was so rude to my mum either. But then, I know that in years gone by, bedside manner was not considered such an essential skill. Now we get to learn these things and hopefully not scar a young mother.

Now I have found another reason for the extreme length of this course (six years). If I were to be a doctor anytime soon, I would induce extreme panic in my patients and turn them all completely off reproducing. [Not that that would be a bad thing for some of them, but then that is not the doctor’s call to make.]

Medical students need time to turn into real doctors: time to get used to scary situations, time to desensitise ourselves, really.

One day in the delivery room, the only people that should be freaking out should be the mum and her entourage.

Endocrine System: When studying for the exam

Yesterday I studied for my Endocrine System exam. I have decided that I simply cannot have a supplementary exam in January as

1. I need actually to have a holiday in the short time provided
2. I won’t be able to take too many textbooks home with the airlines’ baggage allowances for domestic flights

Endocrinology is supposedly the easiest module we do in second year, but I am not sure that I agree. The difficulty lies in the complexity of hormones and the fact that symptoms can be so non-specific. The volume is not so much though, which makes it easier.

I was hoping to diagnose myself with hypothyroidism, but it seems that weight gain, “depression”, tiredness and muscle weakness account for at least half of all possible endocrine disorders.

What I love about this system is that when it works, it works well.

It displays just how well the human body was designed to work.

It is pretty cool that Thyrotropin Releasing Hormone can be made in the hypophysis, travel to the pituitary gland, give rise to Thyroid Stimulating Hormone, which will eventually increase iodine absorption and stimulate the synthesis and release of thyroid hormones. [YES! I remember something!]

This means that if you suspect hypothyroidism, you actually have to look at more than just the thyroid for the cause. Hence the complexity.

Endocrinology explains a lot of interesting things.

For example, did you know that it has been proven that emotional deprivation and other psychological factors do cause growth retardation in children? My Kumar and Clark says so, and it is an excellent text book. The mechanism is not yet understood though.

Also, there is a rough formula for predicting the future height of your children:

The sucky thing about endocrine diseases is that they can be blamed for pretty much anything. Subfertility, erectile dysfunction and high blood pressure can all have endocrine-based aetiologies – but may all have other aetiologies too.

And if your hormones go haywire, you can have some pretty uncomfortable symptoms, like hirsutism (abnormal hair growth in areas that are sex-hormone-dependent) due to excess androgen production, goitre due to some thyroid conditions and eyes that seem to be bulging in Grave’s disease.

Did you know that premature thelarche is defined as breast development at the age of 2-4 and premature adrenarche is the development of pubic hair between the ages of 5-9? And hormone therapy does not even always postpone these symptoms until they are “socially acceptable”.

All these scary things can happen when the little chemical messengers in the body become rogue. Then I haven’t even mentioned the potentially fatal things like thyroid storm, Addison’s disease and space occupying lesions.

The good news for us all is that there is some form of treatment for most of these things. The good news for my study success (hopefully) is that in this module, most diseases’ treatments can be categorised under the headings

1. Surgery
2. Radiotherapy
3. Medicine

And hopefully, with enough hard work, one day I’ll be a good enough doctor to notice these conditions in time and thus make my patients’ lives a little easier.

Introduction to Clinical Medicine: Learning to Listen

One of the most important things they try to drill into our heads at Med School is the ability to take a good, relevant history. If we get a question in a test or exam asking, “Patient X has these symptoms, describe the steps you would take to reach a diagnosis” and we do not start with Take a relevant clinical history, we’re pretty much screwed.

The importance of a history is not exaggerated. Apparently some UK study indicated that over 75% of diagnoses can be made on a good clinical history. I am still scouring Google for that study, so if you know it do pass it along.

Anywho, listening to a patient is not as easy as it may seem. Another elusive study quoted by a lecturer states that on average, doctors can’t go for longer than 18 seconds before interrupting a patient. At the same time, you can’t sit and twiddle your thumbs waiting for a patient to blurt, “I think I have primary hypothyroidism because I’ve been gaining weight and having a deeper voice since delivering my baby so probably is postpartum thyroiditis!”

[Yes, I have been studying Endocrine System today.]

So anyway, in order to teach us this valuable skill, we have weekly roleplay sessions in which we practise taking histories on fake patients. In front of our groups. Behind a one-way window. And we’re not sound-proof. It rattles you, but it is extremely helpful. Afterward the “patient” and the rest of your group give constructive feedback.

Week 1: We learn about the basic structure of the anamnesis (the fancy word for a history). We practise a bit and get  a fright because one actually needs to know stuff in order to know what to ask. AND you can’t get awkward when a patient shares intimate information because you are now there confidant. In fact, you need to get them to share those details without feeling judged. We leave feeling a bit out of our depth.

Week 2: A few unlucky victims are chosen to be doctors. We learn from each other: mind your body language, mind the way you greet your patient. Mind the way your eyes stretch when she says she smokes ten packs a day. Be sure to show your patient to his chair, so he doesn’t accidentally sit in your chair. But if that happens it really is not the biggest trainsmash. Remember your structure. Structure, structure and strucure is what we get out of this session. Don’t float around aimlessly. Have a recipe. Have direction.

Week 3: I get a turn to play doctor. I have taken histories at community service day-clinics before; but it does not do much to ease my mind. I have a recipe. I have direction. The feedback is initally positive. I asked everything. But my “patient” is a nurse and she gave me several cues to follow. Instead, I stuck rigidly to my structure and asked what I wanted, when I wanted. So while I eventually got to all the aspects of her case that I wanted, the discussion didn’t flow. Take a cue if it is offered.

So a good history turns out not to be merely about listening to your patient. Nor is it about having a list of things to ask, or about only getting all the biophysical facts.

Taking a good history is more than a science – it is an art.

Imagine, I actually thought that these roleplays would be a waste of my time…

Introduction to Clincal Medicine: Learning to probe orifices

As mentioned before, I am currently in the last quarter of my second year as medical student. The module my class is handling at the moment is called Introduction to Clinical Medicine. This is where, after almost two years of intense theoretical training, we get introduced to the clinical set-up of medicine. It is a time both exciting and scary.

He who studies medicine withoutbooks sails an unchartered sea,

But he who studies medicine without patients does not go to sea at all.

[Sir William Osler was a pretty deep doctor.]

We have been going into hospital, taking histories from patients and practising our general, abdominal, cardiac and respiratory examination techniques.

Some techniques, however, are best practised in a well-equipped clinical skills lab.

Take for example the gynaecological exa mination. Today it was my group’s turn to be educated in all things orifice-y.

At this point I should mention that our skills lab is probably one of the best in the country and has some excellent simulated models. Nonetheless the vagina we got to practice on consisted of little more than two half-thighs (in lithotomy position), a pelvis, perineum andabdomen.

It would probably be a good idea for these SIMS to be innervated and have the ability to say “ouch”. I’m pretty sure we caused a lot of fissures today.

How awkward practising groping around in a vagina (albeit fake) in front of 20-odd classmates. I got to see a cervix though – hope it looks like that in real life otherwise it’s not really of any use.

Worst realisation of theday? Becoming an OBGYN will not get me out of performing rectal exams. It appears that part of the standard gynae-examination includes a rectal exam. This apparently is firstly to feel the rectovaginal septum and secondly it enables gauging the size of the uterus.

Poor women. Men at least grow up knowing that they will one day need this kind of probing to improve their chances of survival (and healthy swimmers) into old age. Good thing I found this out before my first time at a gynae. [Though apparently, had I studied well enough for my Gynae exam a month ago, I would already have known this. Sigh.]

Speaking of which. I have decided that if I ever went to a male gynae, it would have to be a very experienced one. Those poor boys today had no concept of sensitivity, the way they were shoving those specula around…

Shame, a friend of mine realised that he had inadvertently closed the Cusco speculum around the neck of the cervix and was pulling it out. Talk about iatrogenic prolapse…hopefully that only happens with mannequins.

 

A Cusco Speculum

 

I suppose this is why we practise on dolls first before being given half a chance to do it to a real patient.

So I’ve learnt a few new skills today, but I reckon I’ll be paying the lab a few more visits before attempting any real procedures.

Also… my hands smell of latex and KY jelly.