Graduating from Medical School and Hightailing it to New Zealand.

I’ve recently been looking towards the future and have come to the conclusion that as much as I love the UK I will want a change of scenery by the time I graduate. Hell, I’d be happy for a change of scenery right now.

It’s a long way off, and I imagine I will complete my foundation years here in the UK to allow me to return should I want to but I am sorely tempted to head off to NZ once I graduate.
I have looked into the USA and Canada but from things I’ve heard it seems incredibly difficult to get a training post out there. In NZ things are apparently easier and to be perfectly honest who wouldn’t want to live in a country that seems to have its work-life balance way more sorted than most other places.

Obviously this may be subject to change as I may meet someone and decide to settle down here in the UK, but I can’t help but be tempted by the more peaceful, less crowded and frankly beautiful country that is New Zealand.

It’s a dream and probably a wild one which will never happen but at the moment it is something that I’m really considering. If anyone has done this, what was it like? How did you find the process? I’m struggling to find clear, concise information about the requirements and how to go about moving over. It would be wonderful to hear from someone who has done this and who could shed some light.

Enough daydreaming for one day. I should really hit the books to make sure I get to graduation let alone to NZ!

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!

An interesting case…

Fortnightly we at our medical school take the afternoon to go to a local GP surgery and get some teaching from current GP’s and meet a few patients.

We’ve been going for a few weeks now and I must say our GP is a fantastic teacher, one of those highly enthusiastic people who is ready to tell you absolutely everything he knows about a topic.

Back in our first week we were learning initially about general end-of-bed observations and taking an examination of the hands and face. We learnt first and then to practice what we had learnt on a few patients who had some interesting signs.

One of the patients had psoriasis which on examination of her hands was hardly noticeable but then she rolled up her sleeves and we saw that she was covered. From this I learnt not to just take the surface of things, to dig a little deeper and you might uncover something that you’d otherwise have missed. This would obviously have come out in the history but as we just examining the patient today we could have easily missed it.

By far the more interesting case for me, however, was her husband who just came in the capacity of taxi to bring her into the surgery. He had however had a pretty obvious and extremely interesting operation that I had never seen before or knew existed.

Before he even entered the room we could hear him chatting to our GP in a gravelly, very hoarse voice which at first I just thought was his voice until he walked into the room. It was immediately obvious that he was talking through a valve in the middle of his neck which he pressed in order to make sound and let go of to breath. I had truly never seen anything like it.

He told us that he had had a tumour of his true vocal cords and that in order to be cured he had, had to have a total laryngectomy (surgical removal of the larynx (voice box)). This obviously removed his power of speech however surgery can provide a solution to this. He had, had what is known as a tracheo-oesophageal puncture performed and then a prosthetic valve placed in to allow him to regain a form of speech known as oesophageal speech.

Apparently his degree of speech is very good in comparison to the normal outcome for these patients and I must say that apart from the gravelly tone of his voice his speech was entirely normal. He has learnt to use the valve very well.

The principal of the operation, from my understanding, is that a patient who has had a complete laryngectomy needs to breathe permanently through their neck. A hole (fistula) is made between the trachea and the oesophagus and the voice prosthesis is inserted which does not allow food down the trachea but does allow air into the oesophagus.
Air in these patients enters and leaves through the valve in their neck but when the patient occludes the valve and prevents air escape by this pathway air enters the voice prosthesis and enter the oesophagus and escapes through the mouth. As the air passes through the upper tissues of the oesophagus it vibrates replacing the vibrations previously produced by the vocal cords.

This is what it looks like in the flesh:

Oesophageal speech, I’ve been told, is hard to master especially initially but there are clinics for these patients to go to where they can learn to speak well using these prostheses and the result is truly astonishing.

There are of course implications on this man’s life, he will never be considered in the same way and there will be a prejudice that comes from the sound of his voice. He said himself that children are scared of him now and he does resent that, but for him the ability to still communicate close to how he used to succeeds that and once people get to know him they understand and there is no judgement.

It amazes me everyday the things that modern medicine can achieve and this man and his surgery reminded me why I decided medicine was the career for me in the first place.
Very cool!

Just to show those of you who haven’t seen this – here is a patients story:

https://www.youtube.com/watch?v=SaREnCLP3RM

Why We Shouldn’t Complain about the NHS…

I’ll admit that I’ve done it, and I’m sure we all have at some point. Admittedly when you are sitting in A&E, nursing a concussion only to look at the clock and realise you’ve already been here for 3 hours it is hard to see the rosy side of our healthcare system with it’s long waiting times and ever decreasing availability of services. However we shouldn’t be so fast to complain.

I learnt a couple of days ago that someone I know from America is dying. He has a congenital heart defect and requires a new pacemaker as well as a follow up surgery to try and reduce the defect. Unfortunately he cannot afford either of these things.
And that’s that.
The American healthcare system just watches whilst he dies from something completely preventable.

Now, the American system is fine for those people with insurance and it tries to help those who are the poorest and can’t afford healthcare but it misses a chunk of people in the middle. Unfortunately for my friend no insurance company will cover him with reasonable premiums because he has a congenital disease. So he can’t afford to pay the premiums, and certainly can’t afford to pay upfront for the surgery despite hardly missing a day of work in his life.

His family are very strong and are glad that they’ve had the time that they’ve had. They have accepted that at any day they could wake up and he could not be with them anymore but we have to ask ourselves why they should have to accept this? Both him and his wife work extremely hard, they are pillars of the community and yet because they don’t have the monetary means the healthcare system leaves them by the wayside.

Healthcare is there to alleviate suffering. My friend is suffering because he can’t afford care and his family are suffering with the knowledge that they can’t do anything and will suffer more when he eventually passes away. It’s pretty ironic don’t you think that it is a healthcare system which has caused this suffering?

I had strong and mixed emotions when I heard about this, I was mad that this is happening to such a young man and wonderful family, I was sad for them and then I was extremely grateful. The horrifying truth is that in the UK my friend wouldn’t be dying because we have a healthcare system that is free at the point of access and that does not discriminate based on economic standing.

So yes we may have to wait 4 hours in A&E or 6 weeks for our knee op and that’s annoying, but at least we get care and we don’t have to worry that we can’t afford it.
I have a new found respect for the NHS and the values it upholds and if anyone catches me moaning about it again, feel free to give me a slap!