Another Professionalism Debate

Professionalism is something that I personally reflect on a lot. I want nothing more in my medical career than to do no harm and to be professional so that I provide the best for my patients.
At medical school I always seem to be coming across situations in which I question the professionalism of the doctor/healthcare professional I am working with. I understand that in stressful situations when there is a lot to do and think about sometimes common courtesies get missed, but there are times when I see things that make me question professionalism and how we come across as medical professionals.

The case that got me thinking about this issue again this time was on our hospital placement. Each fortnight we go around the wards and practice on unsuspecting patients our history taking and examination skills. For patients this must be a really daunting prospect anyway. Our hospital tutor goes to the patients and asks them if they would be willing to talk to, and get prodded by the medical students in advance of our session and  if they say yes in we go. There are six of us and you can see the shock and mild panic at the number of students on every patients face as we file into the bay and crowd round them, hemmed in by the curtain. And then our hospital tutor introduces them and we take a history/do our examination. The poor patient has to sit there whilst 6 of us go through the motions one after the other. Nothing we are subjecting them to is painful and I think some of them enjoy it as a way to pass the time but there are occasions when we go in and it is clear that the patient wants to go back on their previous ‘yes’ to being a guinea pig. For example there are occasions in which the patients family are there and they clearly want to spend this time talking to their family member and not to us.
In this situation though what is the right thing to do? Should we be quick (this is often the option that our hospital tutor goes for, allowing only a couple of us to do the examination or taking a rapid fire history himself) or should we recognise that the patient doesn’t want to be examined right now and leave them be. I personally would prefer the latter. Whilst it is important for us to be able to practise examinations, none of these patients actually have signs, we are more just looking at normal at the minute so we can practice on ourselves. I don’t see that there is any need to disturb them when they clearly don’t want to be disturbed. I wonder how we come across if we don’t pick up on these signs and act accordingly and I worry that we come across as rude to the patient.

There was a specific situation during our hospital placement that made me particularly uncomfortable and after discussing it with my colleagues it was clear that they felt the same. There was a patient on the neurology ward who we went to see to practice respiratory examinations. When we entered his bay it as clear that it would be difficult to take the respiratory examination as he had his arm in a sling and a neck brace on and we were informed that we shouldn’t sit him forward. He also had external fixation on one of his legs and it was difficult to get in close to him. I was expecting our hospital tutor to leave him be and not let us examine him because none of use wanted to risk hurting him but he pressed on and let one of my colleagues have a go. As soon as we entered the bay it was clear that the patient wanted to chat, he was talking in confused sentences but appeared to believe wholly that he was getting his point across. What made me uncomfortable was that our consultant completely ignored him and talked only to us. All the time that he was talking the patient was trying to get his attention to tell him his story, from what I could gather, but our consultant continued to ignore him.

This made me uncomfortable. Understandably though we were rushed for time and I know he was trying to get the best for us from an educational point of view. I would have felt much more at ease if our consultant had spoken to him a little, even just said yes at the end of a few of his sentences to appear as though he was listening. This type of thing makes me question how we come across. In my mind that made him less professional but the patient, who was admittedly very confused, didn’t seem hugely fazed. Our consultant redeemed himself by talking to the patient very well after my colleague had finished her examination but it still grated on me that he had ignored him until that point.

It also makes me wonder about a larger problem. The NHS and medical care in general is supposed to put patients first and yet we as trainee doctors are constantly doing procedures which our seniors could perform better than us. How is that putting patients first? It is putting our medical education first surely? Of course new doctors have to be trained for the future well-being of patients and I suppose that finding the balance is the key.

Anyway enough reflection. I need my bed to have a productive day of revision tomorrow!

Our Future Specialty: Getting ahead of the game in medical school?

What specialty we will practice for the rest of our careers is a discussion that frequently crops up amongst my peers at medical school. We have even decided it will be quite amusing and interesting to write down the specialty that we see ourselves in and the specialty that we see each other in and open them in 6 or 7 years time to see how they match up. Could be entertaining. I honestly have no real idea what I would like to put down at the moment though.

Currently, I’ve just picked my area of interest for my BMedSci intercalated degree and have decided to do a project in something related to surgery. I’m currently in the process of chatting to supervisors and coming up with a specific project. Surgery appeals to me because of the idea of fixing the problem that is in front of you, as you see it. I have my misgivings about surgery mostly because of the sexism that still unfortunately exists around this career choice but I cannot deny my fascination with it, and no not just because of Grey’s Anatomy (though I absolutely love love love Grey’s on another note!). I hope that by conducting my research project in this area I can gain more insight into surgery and the demands of this career, because undoubtedly it will be a tough road should I choose to go down it.

It is extremely difficult whilst at medical school to know how to go about gaining the necessary evidence to show your investment in a particular specialty. These days we are told that because competition is fierce we should get ahead of the game and start getting some relevant experience and go to relevant conferences. On the other hand though you can’t go to conferences for every subject and specialty and I don’t want to narrow down just yet. Interestingly a lot of people in their foundation years who I have spoken to have said not to worry about it too much at medical school and just to try and get exposure to specialties that you feel you would be interested in. But then again, having experience such as a publication in your future specialty must surely be a boost?

I recently (I say recently, I literally just) read this article in the student BMJ about what some people had said they would have done differently to smooth out their career paths with hindsight.

Here’s the link:
http://student.bmj.com/student/view-article.html?id=sbmj.g7554&locale=en_GB

(You may have to register for free to be able to read the full article, but if you are interested I’d recommend a read.)

For me at the moment I think the most relevant points are to:

– Take more opportunities to experience different specialties

– Ask more questions about different specialties 

So I will take that into my project and my chats with supervisors to try and gain some experience to see if surgery really is for me and if it’s not then I’ll take a look at some other specialties.

I think that for the most part that is the most important thing we can do in medical school, ensure that we really want to do said specialty for the rest of our careers. By all means if you are certain that being a GP is your calling then gaining relevant experience and publications/presentations in primary healthcare will help you no end but for the rest of us just working out exactly what we want to do is the first, and most important hurdle.

Anyone else reading who is currently in medical school, what are your thoughts on getting ahead of the game?

Revision… WA WA WA

Oh revision, my old pal. You never cease to visit me every Christmas do you? And every Easter, you are so thoughtful that way…

Yes this is another revision angst post and yes this is mostly a procrastinatory revision angst post. I seem to spend my entire life plonked down at our kitchen table, books spread like margarine all over said table precariously adding to the teetering tower of coffee mugs that gets gradually taller throughout the day.

It is more than a little depressing to have nothing more to do with your life than sit and learn neuroanatomy from day to day. On the bright side, one of our anatomy tutors is frankly hilarious and his emails/ e-learning resources brighten up revision considerably. For instance:

I asked him a question by email and I get this response:

Correct!

Scott,
Sent from my IPhone: Android is for suckers.

I probably laughed more than I should have at that, but in my defence revision does send me mildly insane and delirious.

Does anyone else have the need to consume endless chocolate when revising? I do. I’m convinced that over exams I should put on more than half of my body weight again from the number of Smarties that I eat. Smarties are particularly good for revision motivation as you can make a to-do list and put a Smartie next to each item so that when you complete it, you get to eat it! What could be better? My issue is that I just eat them all after achieving one thing on my list, and then move onto the biscuits.
I am of course completely exaggerating. Though I am partial to a packet of Smarties here and there when revising.

To be fair, this year I have drastically cut out my procrastination. I used to be a queen but I seem to be flunking my procrastination class this year. This is, of course, wonderful for my marks. I used to do anything to get out of revision, including pulling out the fridge/freezer to clean behind it something that never otherwise gets done. I also pick back up old hobbies whilst I have no time for them, such as writing. I am in the process of writing a book but I am useless at writing with any regularity and yes, you guessed it, I suddenly get the urge to get writing regularly again when the revision season comes around… typical. Still I’m much better these days and can survive most of the day without procrastination.

She says…. writing a procrastinatory blog post.

Well on that note, I will leave you and return to the coffee cup mountain covered with worksheet snow.

Farewell, see you on the other side of exams. Best of luck with any of your revision everyone.

Thank you for reading!

Neuroanatomy: #1 Extraocular muscles!

Any medical students reading this probably just let out an audible groan. Let me take a moment to join you… *groans*.

Neuroanatomy is, at the present moment, running my life. Thankfully I do have an interest in it and I do want to learn but even then spending hours upon hours in the anatomy lab gets a little tiresome.

SO!

With that in mind I have decided to share and share alike my resources for neuroanatomy for any medical students dropping by who this might be relevant to. Sharing is caring people, and it might save us all a little time in the lab.

Without further ado I present to you, a brief overview of the extraocular muscles. This might be a bit of a strange topic to launch straight into but it is one that I am confident with and so wanted to share.

Extraocular muscles:

The extraocular muscles are responsible for the movements of the eyeball. There are 6 (7 if you count the lovely levator palpebrae superioris which moves the eyelid) and they are:

Superior oblique
Inferior oblique
Lateral rectus
Medial rectus
Superior rectus
Inferior rectus
(Levator palpebrae superioris) 

What do they look like I hear you ask. Well let me refer you to the following beautiful diagrams

Now these muscles are very difficult to see in an actual specimen and are much more easily identified on schematics and in plastinated models. Initially it can be difficult to know which is which but once you have identified them the first time it is becomes a lot easier and their names help substantially.

Let’s hear a little bit more about these muscles:

Superior rectus: originates from the common tendinous ring situated deep in the orbital cavity, it attaches to the top of the eyeball.

Inferior rectus: is in the same plane as superior rectus and has the same origin. It attaches to the base of the eyeball and is difficult to see unless superior rectus is dissected away.

Medial rectus: On the medial aspect of the orbit, also originates from the common tendinous ring. It attaches to the medial aspect of the eye ball

Lateral rectus: Same as the medial rectus but on the lateral side

Superior oblique: originates from the common tendinous ring and passes anteriorly on the medial wall of the orbit, it becomes tendinous and it’s tendon passes through a structure known as the trochlea. By passing through the trochlea which acts as a pulley system the tendon turns 90 degrees to insert on the posterior lateral aspect of the eyeball.

Inferior oblique: does NOT originate from the common tendinous ring. It instead originates from the maxillary bone. The muscle belly passes up under the eyeball before becoming a tendon and inserting on the inferior posterior aspect of the eyeball.

We’ll quickly cover the innervation of these muscles and we’ll in a later post/ a revision to this post look at the action of these muscles. The reason I’m delaying this is because the axis of the orbit is different to that of the eye so the action of the muscles, particularly the obliques, may not be as expected and I feel I can best explain this with a video which I need to film.

So!
The innervation of these muscles is very simple. Remember this: Oculomotor (CN 3) does all except LR6 SO4.
LR6 = Lateral rectus is innervated by cranial nerve 6 which is abducens nerve
SO4 = Superior oblique is innervated by cranial nerve 4 which is the trochlear nerve. (Incidentally another way to remember this is that the superior oblique passes through the pully called the trochlea and is innervated by the trochlear nerve)

Thanks for reading, hope you are somewhat enlightened! I promise to cover the action of the muscles soon!