Author: Bake, Love, Run

I came here to chew gum and kick ass. And I'm all out of ass.

Classroom anxiety.

I’m sure there’s a whole bunch of you studying for those infernal clinical exams, or know someone who is.  I do not look fondly on those days (few do, occasionally you get a misty-eyed consulting waxing lyrical about how they loved carrying their briefcase away), partly because they were, well, horrible and partly because I have classroom anxiety.  There.  I said it.  In public (of sorts).  I don’t know when it started and it was a very very long time before I realised it was a problem, but sometime between high school and med school, I became extremely afraid of classroom environments.  It probably got worse in medical school – there’s nothing quite like being an arts grad in postgrad medicine, busting your arse comprehending a chapter in your physiology textbook, fronting up to class the next day armed and proud with your newfound knowledge…and then getting absolutely owned by your cocky PhD wielding colleague who just happened to do their doctorate on that very subject.  And variations on that theme.  Daily and weekly, for a good two years.  Being the dumbest person in the room for a protracted length of time broke something in my brain and I didn’t realise it for a long time.

It started with avoiding lectures.  Especially the ones where the lecturer was known to pick on people.  The thought of being picked on, of not knowing the answer, of everyone discovering that I didn’t belong there, that I was in some way illegitimate was just too much.  Then suddenly when I began to study, learning new information became anxiety inducing.  I fell into this strange hopelessness that whatever I learned would never be enough, someone was always going to know more, be better, be more worthwhile, which in turn would reinforce that I was nothing.  So I began to avoid studying too.  Then my fears would be reinforced when I did front up to a class, and be berated for not doing the pre-reading, when all my other conscientious colleagues would dutifully know the answers.  The berating then deepened the anxiety and the avoidant behaviour got worse.  Eventually even when I did study, it got to the point in classroom situations that my memory became impaired by the anxiety of it all, and even if I had learned the right answer, it was gone.  Either it never went in from study anxiety, or it couldn’t come out due to classroom anxiety!

Occasionally I would have bursts of ultra-effectiveness, learn something really well, show up to class and know the answer…and then feel like an impostor because I’d learned it the night before and didn’t do it consistently.  Sometimes in your own mind there is no winning.

Clinical exam practice was particularly painful.  You have to show up, or you fail.  So I did.  I still remember being shouted at “DON’T FREEZE UP! YOU CAN’T FREEZE UP ON THE DAY!!” in front of everyone.  And while I showed up, I was still so impaired from the fear of it all.  I couldn’t pre-read because when I did, all I could think about was how I was never going to know enough or be good enough, or be like that awesome colleague who just studied consistently and practiced and did everything right.  I cried every day from that anxiety, and I was very very lucky that I had colleagues who stopped me in corridors and hugged me, or made me laugh to distract me.  Your colleagues are your everything in times like these.

These days I still freeze up.  I still hide in the back of the classroom hoping I wont get picked on.  In medicine people love being the one that knows the most, they love it when someone gets something wrong because we all love to show off our knowledge, it’s like a reflex.  But I still show up and don’t avoid, and sometimes the class is on a topic I know something about and even stick my hand up to answer.  It seems like such a small thing doesn’t it?  I take a lot of notes that I never seem to read, mainly to focus and calm down.  I look at my higher functioning colleagues, the consistent ones and these days I’m in awe.  I’d love to be that person asking the intelligent questions.  Maybe one day I will!

I look back over med school and my early career and wish I didn’t have this anxiety.  How amazing I would have been if I wasn’t so worried about everyone finding out.  Of letting go and allowing myself to be seen as stupid.  Of just letting go in general.  I’d get better marks, get along with consultants better – ah c’est la vie!  And the problem with anxiety is that it’s your normal – you don’t know you have it.  Your brain protects by coming up with perfectly reasonable excuses not to study, not to attend class, your ability to justify it is simply amazing, and you’re generally affronted if someone suggests anxiety to you because you’re so unaware of it.  Excuses are your reptilian brain’s way of protecting itself and it’s so hard to break free of them.  As the exam looms, try to notice it.  You don’t have to ‘fix’ it, just notice.  Through the practice of noticing, you find a new voice that takes you by the hand and leads you around the excuse, it allows you to put the anxiety into words with your colleagues, it allows you to start becoming that amazing persistent person.  And if you notice that it’s a really big problem – find a psychologist! It’s a really really really fixable problem and any performance coaching psychologist or educational psychologist will work with you and tailor a program to take it down from destructive anxiety to the best functional kind.  My very best friends have this amazing ability to take their fear and turn it into relentless study.  I’ve slowly developed the skill over time, and I’m very glad to be able to write this post because admitting it means it’s finally conquered.

Yesterday was Crazy Socks 4 Docs Day and this post was written in support of physician mental health.  We all suffer in this job and we are all in it together – I hope by admitting one of the things that has crippled me, that my readers can find a little solace.

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On taking a break.

I am on maternity leave (again), with baby number 2 (she is beautiful and perfect and all good baby things). It occurred to me that this is the first time since starting medical school, that I’ve had a real break.  The first round of maternity leave was filled with exam study while learning how to be a mother.  You don’t realise how fraught you were as a new parent until you have a second!  Newborns are actually pretty easy, they sleep a lot and can’t run off on you, waving their pants in the air, bare bum disappearing from view.  I digress.  Holidays aren’t really a proper break, although to be fair, I’d had proper holidays denied since 2013 for a variety of classic medical workforce excuses, which one day I’d like to turn into a bingo game for all junior doctors to play, so pervasive they are.

And here I am now, with 8 glorious months off work.  It’s hard to put into words what a proper break from medicine feels like.  It’s like there was this giant piece of furniture in my mind that I didn’t know was there until it was gone, and suddenly there’s all this space in my mind.  All the things that were so hard to do before are suddenly easy.  Exercise?  No problem.  Healthy eating?  Too easy!  The other thing I realised is just how anxious we all are at work.  I’ve been reflecting on some of the advice I’d received over the years, which frankly, has often been terrible.  I remember in medical school, telling the gunner resident I wanted to do physician training.  She archly told me that I needed to start studying now (in 4th year med!) if I wanted to pass it.  Or this strange phenomenon of everyone putting their basic needs, like using the toilet, eating, or forcing down tears, enjoying their partners and friends, absolutely last for very little yield.  I’ve never been an angel in this game, but I’ve fallen into that trap time and again.  It’s so consuming.

Taking a break is like stepping into an open field without anyone there, but with all the knowledge and all the lessons you’ve learned so far, right there with you to examine.  It’s like getting to start again, knowing what you know now.  There’s so much pressure to stay on that conveyor belt, to never get off, that Something Really Bad will happen if you take time out to rearrange your head after so many years of grind.  You get a lot of bad advice from well meaning but out of touch people in this game.  A lot of that advice comes regarding parenting in medicine (given by people who’ve had the luxury of having a wife managing their entire home life), and taking time off (given by people who’ve never had time off and have developed maladaptive ways of dealing with things at work).  So many anxious people relaying their anxieties in the form of bad advice.  Things like “you can’t have a year off without doing something medical because people will think you did nothing”.  Like, you just sat there and stared at a wall for a year?  Like taking time to better yourself, or expand your horizons, or raising kids is nothing?  Sometimes becoming a better doctor has nothing to do with medicine, and everything to do with where you’re at in your heart and your mind.

I know the clinical exam is coming up.  I remember so well how I felt afterward.  I wasn’t brave enough to take a year off after that.  Even a few months would have been enough.  I used to be so scathing of people who quit before their contract finished, but I get it now.  It’s not great that it happens, but I so get it.  It’s a function of a system that pushes people to the edge, and walking away probably does pull those who do it back from the edge.  I wish there was enough redundancy in the system to allow trainees a proper break after the exam onslaught, not the token couple of weeks you’re graced with.  When you’re at the coalface of human suffering, combined with those exams, and all of the personal life you miss out on, compounded by all those previous coalface years, it changes you.  Taking a break, whatever the reason, is breathtaking in that once the job falls away, you’re met with the self you thought you lost all those years ago.  If you can, do it.  If you can’t, plan for it so that at least it’s on your horizon.

Oh, the places you’ll go!

I was looking through the archives of this blog (now added to the sidebar) and had to shake myself – wait, I’ve been a doctor for 7 years?  I’m PGY….7?!  When did that happen?  I feel like internship was yesterday, I feel like I was scurrying around the bowels of the hospital, the weight of responsibility for every patient ever weighing on me, and the anxiety that I had normalised crushing me like a vice.  Struggling to find something to write about, I had a look through some old posts and realised that I had so much free time before I had a child!  I thought back then I had no time…but goodness, knowing what I do now, I felt downright jealous of myself.  All those posts with food experiments, sewing, coherent musings on life.  Of course, my daughter is the absolute light of my life and I wouldn’t trade any of that for her, but how strange time as a concept is.  We never think we have time.  We have one child, no time, and then people go on and have 2, 3, 4 and laugh at their earlier selves.

Anyway, PGY7?! (Post-grad year 7 for the uninitiated).  On Facebook today I saw some colleagues had got through their surgical fellowship exams and I felt so proud.  It is such a long, long, long road.  From that first year of not knowing what the hell is going on and feeling stupid 120% of the time, to that year of overconfidence of residency, then back to feeling stupid 200% of the time, of being that person in the room where everyone is nodding at the lecturer and you’re pretty sure you’re the only one who doesn’t understand, to those effing exams, and then onto advanced training…and all of your own life in between and that’s not even close to putting it into words.

7 years ago I wrote a post about choosing life over prestige.  About your head is filled with noble ideas of curing cancer, and doing highly ranked research, of doing the super duper prestige specialty.  I mused if intelligent and smart people also did the less prestigious ones (they very much do).  And I said I felt like physicians were the guardians of humanity.  Virchow once said that “physicians are the attorneys for the poor” and in my 7 years I have learned often that he was right.  It’s not until you do physician training that you realise the power of advocacy, of advocating for your patient – and their family.  I can’t tell you how many consults I’ve had where someone’s discharge has been delayed because of ‘unreasonable family’.  But usually they’re people who, in terrible circumstances are afraid and not at all understanding of the behemoth they’ve been forced to engage with.  I’ve written countless medical reports in support of my patients to help them escape terrible situations, I’ve kept them in hospital for this.  And I’ve argued with so many teams about not sending people home, teams who are getting crazy pressure about ‘beds’ and ‘lengths of stay’ (the amount of time a person spends in hospital – the hospital only gets money for a certain amount of days and past that it’s out of their budget), where I’ve had to pull the card that reminds the other person on the other end of the phone that my focus is on what’s best for our patient.  The managerial overreach seems to get worse every day, and every day I daydream about how well we could do with endless money.

When I was more junior I used to think that the ‘serious’ medicine was in the knowledge.  In the research, in the molecules, in the jargon.  Maybe it is, I’m not sure.  For me the medicine now lies how to improve lives.  Not just treat diseases.  Anyone can memorise and spit out a treatment protocol.  It sounds really impressive when you do.  But learning how to step back and say, hang on, what’s going on here?  What’s happening in this persons life that is contributing to this?  This is the part of my job that I love.  It took me a while (and some horrendous exams) to stop reducing people to a list of jobs, to a list that I constantly wanted to shorten and start listening, and working out a way forward without having to spit out treatment plans.  Those plans are important of course, but with every human you encounter, there is a bigger picture.  At some point I had to relearn compassion.  Pain is real, even if someone else’s pain annoys you.  The elderly are part of who we are, they deserve all of our respect, all people do.  Compassion for stressed out and anxious families needs to be endless, we need not be combative.  And compassion, not empathy is ultimately what gets you through.

PGY7.  Not even including medical school.  Years and years of facts and physiology, of problem solving. And for junior me, and junior you – yes it’s worth it.  I never knew the power of this job until I got (for me) what it is really about.  It’s sticking up for your patients, it’s wanting better for them and their lives, it’s asking them and yourself how you can achieve it.  It’s demonstrating patience, compassion and endless validation and reassurance.  Your knowledge keeps up on it’s own after a while.  But the other stuff is an endless and wonderful practice.

Art, science, medicine, outrage.

I’ve seen come (and might have weighed into) some disturbing arguments on Facebook lately.  Things like cannabis oil being the magical hidden cure for cancer that millions of doctors, pharmacists, researchers and evil Big Pharma corporations are part of some sort of conspiracy to prevent the ‘truth’ coming, anti-vaccination, and so on.  And what I’ve observed is the complete inability of both sides to appreciate the thought process behind the other.  It’s like watching engineers try to communicate with graphic designers.  Painful.  There’s a lot of layers there, complex layers of emotion, past experience, fear, anger, guilt, and shame.  There’s a lot of shame.   One argument was that they would not be ‘blinded by science’ or science’s ‘big words’.  It was telling.

I’m in the somewhat unique position of being someone with an arts degree, a degree in medicine, and a parent who died of cancer, trying desperately after all treatment had failed to cure themselves with the magical cure du jour (Essiac if you’re interested).  The parent’s death happened first, followed by the arts degree, and finally the medical.  And sitting back and observing these raging blistering arguments on Facebook, worse on Twitter, has really got me thinking about just how far apart the fields of art and science have been driven, and how both have been siloed so much, that neither has any appreciation for the other, when they’re more intrinsically reliant on each other than most realise.

In my arts degree, I learned the power of the argument.  If you have a thought, and it’s plausible, you can argue your position until people agree with you.  You can redefine anything, that is postmodernism, you can question the meaning of everything, you can change it’s meaning if you want.  Gender is no longer a word that means male or female for example, and given the addition of social media to postmodernism, anyone’s opinion and definition is just as good as anyone elses, so long as you can find other opinions to back yours up.  And of course you can.  This of course, completely throws out respect for expertise, for process, for the years of honing ones craft that is science, or law, or engineering or medicine, or fine art or any of those things that suck you into a black hole of effort for years, only to emerge alone in a sea of Facebook opinion without any understanding of that process.  I think back to all of my essays, thousands of words of beautifully crafted arguments, backed up by leaders in the field.  All HD’s.   Your opinion is as valid as everyone who agrees with you.  You can use anecdotal evidence, indeed you’re required to, individual arguments are much more powerful and hard hitting.  It’s how the social sciences department of Wollongong University got an anti-vaccination PhD through – it wasn’t scientific, they could argue whatever they wanted and once backed up, it was valid.  It’s easy.  And it has a role.  Post-modernism has been wonderful at questioning those oppressive cultural norms, at deconstructing them and asking the hard questions of who we should be as a people.

When I started my medical degree, I’m a little ashamed to say that I had very little understand of the scientific method.  I would say that most people don’t.  I had to bring my year 10 level science up to scratch for the GAMSAT and that was painful and confronting.  There was shame.  It was the root of those ‘blinded by science’ arguments because studying science when you’ve grown up in an environment and culture that tells you that you can’t possibly be good at it because you’re a girl, feels like wearing a bikini in a blizzard surrounded by people in snowsuits.  It’s uncomfortable and painful and for me it was embarrassing.  The scientific method actually describes a process and it is the process of creating a fact.  People seem to get opinions mixed up with fact, as if one something happening to one person somewhere in the world can be ‘proof’ and not just a statistically random event.  How could you possibly tell the difference if you had no idea that a process existed?  And most really don’t.  The scientific method and the postmodernism argument actually have the same first steps, but science continues where postmodernism stops.  You have your opinion (your theory), you do your background research to see what has already been explored for that theory, and then you construct your argument (your hypothesis).  Postmodernism ends there.  What science does, is take that hypothesis and challenges you to carry out an experiment to prove or disprove it.  There’s the major difference.  There is supposed to be an impartiality there – you don’t emotionally invest in your hypothesis, the true unfeeling scientist does not care if it’s right or wrong, they just want to prove it either does or doesn’t exist (I say supposed because we’re all human and we all emotionally invest).  If your hypothesis was that gravity pulls you toward the earth, you could drop 100 balls from a height and argue that they would all fall down to the ground.  And so they do.  Your hypothesis is proven.  The next step is to then communicate your results, and crucially, other scientists then have to repeat your experiment and get the same result.  That is how a fact is born, a drug is made, an intervention realised.  And on the subject of drugs – first you have to prove it in a petri dish, then in an animal, then in an animal more like a human, then in a few humans, then a few more, then a lot more, and then others have to prove it, and after it’s on the market it has to be followed up and side effects reported into a register to make sure you didn’t lie about the whole thing.  This is done to avoid killing or harming people.  It takes 10 to 15 years and involves hundreds, if not thousands of people.  Watching the Charlie Gard case, where a doctor, a medically and scientifically trained doctor, offered a ‘treatment’ that was nothing more than a hypothesis, gave me chills.  It was my medical degree that taught me about process, of due diligence, and how gravely important these things are.

The chasm between the two fields grows greater every day.  I’ve had anti-vaxxers direct me to books by scientists and doctors, weighing into the ‘conspiracy’ for the great price of $29.99 (at least someone is making money), well written, plausible sounding books, all by scientists who appear to have completely forgotten about everything after step 3 of the scientific method.  There are so many vested interests, so much money changing hands for this crusade, and I am yet to see who benefits.

I think back to my father, desperately steeping that stupid tea into bottles and I get it.  I got it well before I ever did medicine.  You can’t use science and impartiality and common sense against the weapons of grief and loss and shame and fear.  Those feelings need to be named, the backstory needs to be understood before you can even start to have the realistic conversation, if you can even have it all.  I think to all the family meetings I have, day in day out, where I break bad news, where I tell people it’s not safe for their parent to go home, that they have a terrible progressive disease and no one wants to hear it.  Who would?  I don’t argue, I don’t respond with Facebook style outrage.  I acknowledge the fear and the pain.  I stay silent while they rage.  I tell them I’m sorry.  I don’t push the facts on them.  They stand silently on their own, proven by blood tests and brain scans and screening tools.  I think about those Facebook arguments, so fraught, so filled with outrage, so many complex layers of emotion – people’s backstories playing out through the lens of the argument du jour.  So much lack of understanding on both sides of each other’s process, how they came to be where they are and of who they are.

Barack Obama said in one of his final speeches, to get off the Internet and argue in person.  He was right.  You can’t truly explain your position, on why this is so emotional for you on social media.  One thing I learned in my arts degree is that ‘the medium is the message’ (McLuhan) – which means that it’s not just the content of the argument that is being conveyed that is the message, but that the medium which is being used is too (and he said this well before any meaningful social media).  Facebook, in spite of using real names, teaches us distance from each other, it teaches us mass outrage, mass bullying.  That if you have an opinion, be prepared for abuse and humiliation, of people shouting you down.  You internalise that message and carry it into the world and feel isolated and afraid as a result.  And in isolation your opinion starts to become a fixed and unmovable belief, often to the extreme.  And you find others within that extreme, people who ‘get’ you, so you’re not isolated anymore.  It’s us against them.  Except what you don’t realise is that everyone is doing it, just in different sets of fixed beliefs.  No one is much different.

So that’s my opinion.  None of it is fact, it’s mostly just observation and can easily be argued with.  What I’ve realised from all these observations is that we need to get the f*** off the Internet and get back into our world and talk to each other, without the backup of a thousand Internet bullies behind us.  Scary isn’t it?

You have to find the bright side.

We’ve had a lot of media coverage about how hard being a junior doctor is now.  It’s barely the tip of the iceberg but it’s given me a lot of pause, and now that I’m part time, working a subacute job in an acute hospital, I actually have more time to listen to what’s happening around me.  It’s not pretty.  I overhead an intern replying “or, I could put a knife through my heart” when told she needed to do a discharge letter right now because the ambulance was there.  No one had warned her.  Discharge summaries take a while to write and she was mid-ward round.  I saw another guy slamming the desk repeatedly because hospital computer systems.  When I went to see a consult I noticed the intern was pale and shaking and when I told her gently that she was doing a good job, she collapsed into tears.  Her registrars were being arseholes, because their bosses were being arseholes, and she didn’t play the ‘flirt with your registrar’ game.

And for a while there I felt pretty down.  All that media coverage, all that I was witnessing, not to mention my beautifully suppressed own horror stories, and reader, I could write a trilogy and come back for two prequels with all the terrible stories I have, it was so much.  The media would love my stories.  And they’re never going to get them.  The media coverage has given me this strange sense of contagion and in a way, it’s made things worse.  This had to happen, it had to blow up, and it was always going to but the more I read the more it brings up for me and I was lucky enough to make it through junior doctor life in spite of my horror stories.  I maladaptively coped in my own ways, I stepped back from the glory of the acute limelight in the grey area of a subacute world that isn’t glamorous, that doesn’t aim for cure of anything but focuses on quality of life, sometimes at the expense of length of life. I found the people who think and feel like I do and I joined them.  And when I’ve done my training, I’m not interested in a system that eats it’s young.  I’ll stay in it to some degree because you always need the peer review of a public hospital, but that once noble cause of contributing to free healthcare for all in a collegiate system of respect (not to mention residents quarters and feeding the staff) is gone, fallen victim to an intensely cynical political environment focused on numbers that can’t be perceived to be giving ‘handouts’.  The result is everyone measuring themselves by numbers, how can we reduce the numbers, how can we turn them over, how much can we do in the community that we don’t have to do in hospital (hint: nowhere near as much as you’d think).

However.  I did not make it through this far by focusing on all the failings of this system.  Your life is very much dictated by the lens through which you view it and you can throw on the green glasses or you can throw on the rose glasses.  Choose the green glasses and everything looks sick and rotten.  Choose the rose glasses and everything is warm again.  The greatest thing that medicine has ever given me is collegiate relationships, of genuinely liking who I work with, and you can see this everywhere.  They’re tiny little moments that get drowned by all the traumatic stories, self doubt, horrible days, days where you don’t eat or pee but they’re there.  It’s the nurse who hands you a cup of tea and a biscuit, or put in that catheter for you because you’d done a grand total of one but back in Hong Kong they were the catheter nurse but aren’t allowed to do them here because paperwork, it’s the colleague who listened in the corridor to your bad day even though they had so much work to do themselves but don’t mind because they get it.

It’s the consultant who buys you a coffee and takes you to lunch even though you can’t figure out why because you never feel like you’re up to scratch (hint: expectations are lower than you think), it’s the guy down in rostering who sympathetically listens to your rant about the unsafe roster and actually changes it, it’s the person you’ve never met who asks if you’re okay then hides you in an unused office so you can cry it out.  There are people who care everywhere.  You can’t see them because you’re so afraid, so wound up, so withdrawn and scared that someone might find out how you’re feeling.  You feel like you’re alone in this world of overperforming heartless extroverts who loudly tell you that they have no idea what you’re talking about when you complain about how hard things are (hint: that’s their way of hiding it).  And yet, here you are back at work, tired beyond belief and unable to remember when you last washed your hair, and there again is the tea and the biscuit, the registrar who buys you a coffee, the nice lady on the switchboard who asks how you’re going.  We are all here.  We are all here for you.  We might not be visible immediately – but that person who stays to listen, who gives you the biscuit, who hides you in the office, those are your people.  Get their number, find them again.  Find the rotation where you got along with everyone the best and consider that as a career.  I was presented with a very clear choice of pursuing a field where I could not be more different in personality to the people I’d be with, vs the one where I loved everyone.  I chose the latter and haven’t looked back.  Don’t be afraid of finding your people even if the path is different to the one you envisaged for yourself.  Our values and ego don’t always line up, but if you can put your values above your ego and live close to them, you will be happy.

I can’t fix the culture.  I’m sure as shit not going to tell you to ‘build your resilience’ because that’s bullshit – you are not the problem here.  Find your people, get home from work and get on the couch with a block of chocolate and some binge TV.  Buy an expensive handbag after your run of nights.  Go on holiday to Europe and eat some food, lie on a beach in a tropical place and do nothing.  Find the things that make you go “aaahhhhh” with happiness.  Learn to shake it all off a little bit because you’re really not the problem, and you’re okay.  Learn to laugh at it a little bit.  Because slowly but surely it does get better as you gain knowledge and experience and autonomy.

And if suddenly you find that all the things that used to make you go ‘ahhhh’ simply don’t anymore, if you find yourself wondering who you are because you don’t like your favourite food anymore and can’t get excited about going on holiday anywhere, this is what you need to do.  You need to buy private health insurance.  You need to find a psychologist practice as physically close to you as you can find.  You need to ring them up and tell them you need to see someone.  You don’t need a GP referral, you can just pay privately if you’re more comfortable with that.  When you go to that appointment, all you need to so is sit down in that room, and say “I don’t want to feel like this anymore”.  Your psychologist will take it from there and you just need to let it all out.  You need to buy your psychologist chocolates at the end of it all because the person you will be when you leave that room will be greater than the one you have ever known.  I know you shouldn’t have to, I know none of this is your fault and why should you have to put yourself through this when other people made you feel like this?  The answer is, because you don’t want to feel like this anymore.

Find your bright side.  It’s in the dark humour, the biscuits, the strangers who listen and the colleagues who care and the psychologists who are visibly horrified by your stories and want to help you feel better, who tell you that you’re fine and the system is royally f***ed.  It’s in your family who welcome you home where you’re warm and safe and fed, and the friends who laugh and cry with you.  Keep showing up each day and doing what you do.  We all appreciate you, we know you’re doing the really high volume stuff.  Keep trying to find the bright side, no matter how small, let the cracks of light in.  Try to sleep as much as you can.  Learn to say “f**k it I’m having lunch” even if the other juniors look at you funny and watch how the sky doesn’t fall and the sun keeps on rising.

Looking at life.

I was reflecting on my very long time online last night, made possible by a random sequence of events in the mid-1990s.  Those days are very long gone, as is the Internet as it was back then, it hasn’t really been archived and these days it feels a lot smaller, and a lot more corporate.  Gone are the days of it’s existence largely as a scientific information-sharing service, largely populated by enthusiastic geeks.

I thought back to my old blogs (also long gone) and how so much of what I wrote about was the day to day life of a twentysomething uni student, all the music I liked, and hobbies and random things.  It’s so easy when you’re a doctor to live that role when you get home from work, but of course, if you let that happen, when retirement comes, you might as well scoop out your soul and leave a shell of yourself.

So here is my proof that I do things other than medicine.  I do things.  Like, go to the aquarium with my daughter who has a natural affinity with penguins.  And they with her.

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I also work on my home, which we are not into a year of owning and like to bemoan how poor we are.  Like gardening.  Attempting gardening.  See the dead grass?  It died in a very neat line along the length of the fence.  If you look over the fence, the neighbours have done some gardening of their own.  Just saying.  This is an orange tree.  I hope.

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You may not know that I am a Swarovski addict.  I don’t care what anyone says about it.  It is sparkly and stays sparkly.

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I am also a big fan of high tea with friends.  I like to work my way through high tea venues in cities.  Where else can you legitimately drink champagne and eat cakes without anyone getting judgy?  This one had an all you can eat chocolate bar after the scones and whatnot.  It sounded good in theory.  It is a double edged sword laced with delicious poison.

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Meanwhile I continue to drown in college requirements and oddly sexist comments about part time doctors but what can you do?  Work finishes, and the cake awaits you on weekends.

 

Ten things everyone should know about geriatric medicine.

  1.  High level care does not mean bed bound and demented beyond humanity.  Often it can mean doubly incontinent but completely with it and social and happy.  If you receive a patient “from HLCNH” this is not license to immediately turf them back because you’ve made the above assumption.  You must ask why they are in this level of care before you decide.
  2. If you can’t quite tell if someone is delirious, before you do that B12/folate/TSH arrangement, try  download and print out a CAM or a 4AT.  Both are four short questions which will help you.
  3. Nursing homes aren’t called nursing homes anymore.  They’re called “Aged Care Facilities”.  Why?  because it’s misleading to call a facility a nursing home when there’s no nurses.  There’s ‘carers’.  And maybe one RN to give out the medications.  Nursing homes are not like mini hospitals.  There is no inprest.  There is no bladder scanner.  Sending people back there with drains and medications that need dual signatures will score them a trip back to hospital.
  4. You don’t have to get the not-for-CPR form signed on the first phone call but it’s good to ask anyway because advanced care planning is a process and family members need time to think it through and have lots of discussions.  Initiate the discussion.
  5. Elderly patients can have acute abdomens too.  They might not be able to tell you where the pain is but it is up to you to think of it and if you suspect it and can’t rule it out with the history, rule it out with the CT scanner.  Non-con will still show a mass.
  6. Pneumonia and antibiotics WILL send the INR sky high.
  7. Listen to the family.  Listen to the family.  Listen to the family.
  8. If a nursing home can’t give the palliative medications overnight, and you don’t want to get the on-call pharmacist in to dispense them, don’t discharge them.  Not only is it obviously cruel, but it’s also illegal to deny a patient palliative care and it could be career-ending for you.
  9. An inappropriate investigation in this cohort is one that will cause harm.  Most of them don’t.  And while it may not change your management, the family sure do like to know what has caused their dearly loved mother to start to die.  It’s called closure.  Obviously don’t do a PET scan but it’s okay to investigate even when it seems futile.  Never use the word futile out loud.
  10. Listen to the family.  Even if they seem unreasonable and ‘demanding’.  There is no greater power than love.  It drives people to madness.  Listen to them, try to accommodate them, take a deep breath and be patient.  And when they say “something is wrong”, find that something because 99% of the time they’re right.