Titanic, numbers, medicine

Coming to the end of study week creativity, and blog wars (which I clearly won, muhaha).

During study week, I spent more time on numbers, than I did on medicine. Mean, median, life tables, cumulative incidence, incidence rate, binomial distribution, normal distribution, and so on. Statistics. Yawn? I thought it would be. But it was fascinating, the assumptions and stories behind these ways we use to summarise information.

One set of data really caught my attention. Survival of passengers aboard Titanic (see more detailed figures and analysis). What a story numbers tell!

"Those poor poor people," my friend said. Indeed, it does not take long before you feel the injustice seeping through the page (computer screen). Were the rich informed first? Were the poor systematically excluded from the lifeboats? Was wealth a measure of how much a person's life was worth? There are even journal papers discussing these questions.

The numbers tell a more noble story too, of how women and children were preferentially saved. It's sad - picturing these agonising decisions of who should live, and who should not. The rush, the terror, the scramble to safety, before your ship sinks out in the middle of a cold, cold ocean. Chilling too to wonder, when it comes down to it, would I not also push people out of the way to survive?

Would the movie Titanic be more powerful than these numbers, in impressing these images and emotions within me? I have never watched Titanic by the way, so I could find out, if I wanted to.

Working out answers to mathematical questions recaptured a period of time before university when I really enjoyed learning. The type of interest which consumed you, as much as a good novel you were reading, or a drawing you were working on. Not that maths was my favourite, but I have always enjoyed working out problems, doing questions to learn (like physics). Rather than areas which relies heavily on descriptions, and a good memory (like biology, which I didn't take up for that very reason). When I can and do study, the week before exams is usually one of my favourite weeks of the semester - sleep, eat, procrastinate, study, repeat. But I think, the contrast between intriguing Titanic figures and preparing for exams, has reminded me once more of why I don't find the subject of medicine very exciting.

I have come a long way from first year where I truly fell asleep through almost an entirety of one lecture, every single day. Sometimes I didn't understand the words they used, other times I couldn't see how I was supposed to remember step by step, what goes on in some long and boring biological pathway. Then somewhere during clinical school, I realised to my delight that understanding and problem solving was part of medicine too. Having not much knowledge of the details, you can still work out a basic history to ask, physical exam to perform, investigations to perform, or management issues to consider, for any condition or presentation.

You can get by with that, but it can only get you so far. You will always have those random lists which don't make sense. Obscure symptoms and signs which are barely logical, eponymous names which collect symptoms which should not even exist together, specific terms for radiological findings, associated conditions - some which feel associated, but most which feel unrelated, criteria for scoring for diagnosis or prognosis, staging systems for malignancies. Then drugs, with their hard to pronounce names, side effects which affect every system, dosages which can sometimes vary with brands, even for the same generic medication. Or expected values for this and that blood test. Or fanciful bacteria and parasite names, or body parts in full glorious Latin. And so many acronyms and mnemonics, that I might remember something amusing like I GET SMASHED (aetiology of pancreatitis), but barely remember what each letter stands for.

To be more than mediocre, you do need to remember tiring terms, long lists and fantastic figures. Physician training, or most areas of medicine really, seem to favour people with good memories. Which I lack; I would say, in general people don't get excited about an area that they are not good at. So I wonder at times, would I better utilise my strengths elsewhere, or would there be a suitable area in medicine? Or, would that matter less when you spend more time working and learning, rather than reading and learning? Would people be interesting enough that it wouldn't matter how interesting or disinteresting anything else was? I don't know, but I guess we will know, in time.

Ward rounds

Memories of aged care

I wanted to write these things down months ago but never quite got around to it.

In aged care, I came across a consultant who was had this almost mean smirk on her face constantly, and spoke softly but harshly. She hardly said hello to patients, ever. One day she pinched an overweight lady's abdominal fat, wobbled it around, and then asked her - "what is this? You need to lose it." The patient said oh, with surprise, and I was equally surprised. Another lady had an unusual gait, and this consultant demanded to know "Ms X, why are you dancing like a ballerina?" What a strange sense of humour.

It was disheartening that the attitudes of the senior doctors were readily followed by the rest of the team. I remember an old man who the team rolled their eyes at and dreaded rounding because he always complained. As they whisked through his daily observations, talked about his condition and ignored his attempts to engage in conversation, he demanded with his gruff slurred voice - "aren't you going to talk to me?!" Having plenty of time as a student, I answered his questions about what was happening, and listened to his story about the apparently inattentive overnight nurse, and just a few minutes into the conversation, he (quite appropriately, and thoughtfully) said I should really go and catch up with the other doctors.

Somewhere during those weeks, I noted to myself to work hard to be a normal person, to say hi and bye, as you would in any other situation. And to do that even if the tension of scribbling madly, listening to multiple conversations and rushing off to see the next patient pulls you in the opposite direction.

My clearest memory of aged care was this man in his nineties who always greeted us with a hearty good morning, and winked at me, once or twice. I guess he (and others like him) remind me of my grandfather, who is so stubborn, but doting. Anyway, this man had been in hospital since the first day of my six week rotation and was there until something like my final week. Unlike many of our patients, his mind was sharp, and each day there was a pleasant albeit brief conversation. He had heart failure and I was supposed to complete an observed physical examination on him. Before the weekend he had been sitting up, and was getting ready to leave as soon as home supports were in place. Then he developed pneumonia, and was back in bed. I wasn't there to know the details but over the weekend his infection continued, he had acute renal failure, and ultimately died of a gastrointestinal bleed. So I had to find something else to do for my assessment. But that was okay. But every time I walked past his bed, or when I later saw his name on an old handover list, I would feel a bit sad, and wonder about where he was now (not his physical body of course).

The surgeon and his (her) minions

Groomed, with large leather bags or expensive handbags (I was curious and took a look inside, one was filled with multiple medical journals, another with an iPad and a very fat wallet). Hands on hips, arms crossed, walking deliberately, nodding, firing a question here and there. Talking amongst each other as if there is a massive gulf between themselves and the rest, joking darkly about people dying and having metastasis spread everywhere, complaining about the public hospital system, having lists cancelled, etc. Yes, this is your friendly consultant.

Then there are the in-betweens. Energetic but laid back, presenting with confidence but not yet arrogance and self importance, with distinct character but not yet obnoxious or growing an unsightly Hitler-styled moustache, probably having enough to indulge in delicious food but not entertaining a lifestyle of obesity yet. I guess, it's just a matter of time until these registrars become the men (women) in suits.

The team's secretaries - holding piles of papers, running to get files, scrambling to write down notes, looking intently at everyone who is talking, opening doors and stepping out of the way. Anonymous (the intern said so, not me). Behind them, the non medical staff, usually women, sometimes in alternative outfits, with large dangling earrings, talking indiscreetly about how doctors never actually talk to their patients.

Then there's us, with minds half there, half elsewhere, with our short attention spans. Standing at the patient's end of the bed (because there is no room on the foot end) wandering what he or she feels about the mass of doctors who swarm on them every morning. Wondering why this ward smells different to the next, watching the blood nurse sucking blood skillfully like a vampire - okay not really she is just doing her job. Seeing the multiple bouquets of beautiful flowers one patient has and wondering what makes a person have more flowers and cards than the person next to them. Reading educational posters and random signs and notes, looking out the window and looking at the city skyline in the distance. Admiring a colourful fish painting down the corridor and wondering whether a staff member painted and framed it there, or whether it was just a donated gift. Eyes lighting up to a multidisciplinary meeting - a platter of fruit, adjacent to an assortment of muffins, and delicious bacon and egg breakfast rolls. Mmm, that is what I came in for today!

I guess what goes on in hospital life, whilst familiar, still strikes me as strange. I'm surprised that what I paid attention to, the way I perceived my surroundings during those first ward rounds, are quite similar to what I have described here, on my last ward round as a student. Do I really have to switch roles? I don't really want to...

From the other side

The ambulance call

"Can you have a look at her?"

That morning I was awoken by distressed cries and loud bangs on the door. Her tongue was swollen, in pain, and she couldn't speak or eat properly. The ambulance was called.

Sleepily I sat on the couch beside her. Ironically, we had just revised the ALS protocols the previous day. Airway, breathing, circulation. Tongue was mildly swollen but nothing else to suggest anaphylaxis. No respiratory distress. Er, what else would cause this? I sat in silence, watching her cry and struggle in agitation, unsure of what to say or do, not knowing whether it was appropriate for me to examine her further or to try to calm her down. Sorry, I wish I could have been more helpful. Fortunately the paramedics arrived, and I watched in marvel at how they turned chaos into peace; just simple measures of putting on a saturation probe and listening to the lungs, or speaking to her in a calm but authoritative tone.

Greeting the second ambulance that arrived, I stood sleepily on the front steps, with messy morning hair, in my bright stripy pyjamas. Are you the patient, they asked. Is she your sister? What?! Being used to the assumption that I was part of the medical team (even as a student), I was taken aback by the question. Then, I struggled to give a concise briefing on what was happening, especially not knowing how much of her past history to say or omit with her there in front of me. What did I do all those long case presentations for if I can't give a one minute handover?

I reflected, was it the hospital (or clinic) environment, the medical gadgets there, the doctors and nursing staff surrounding me, that bestowed upon me an ability to think and management problems medically? Void of those, I felt that a layperson could have handle the situation more appropriately. Maybe that's why unlike some of my classmates, I'm not excited about the prospect of finding myself in the middle of an emergency on the streets or on the plane. Surely, had I been dressed for work, wearing the stethoscope around my neck, hospital badge clipped to my shoulder bag, walking down the Emergency Department, the same presentation would have been met with a more active response than simply sitting beside her once I worked out that there was no immediate risks to her life, and that she was far from needing chest compressions. Yet it still makes me doubt whether I can be a doctor at all.

The inpatient

"Doctors! They can't make up their minds," she told me in exasperation, about how her elderly mother with rectal bleeding was managed on the acute wards.

One day they prepare and fast her, the next day they say the procedure is too risky. One they they want to do the colonoscopy, next day they decide to do CT instead. Now they scheduled a PillCam for next week. Angiogram was planned and cancelled. She's working but visiting the hospital every day, feeling frustrated with the decisions that are being changed all the time, not certain of how long this will go for.

So that's what it is like from the other side. Not that patients and relatives don't express similar frustrations during their stays, but I guess it's different when someone confides in you outside your medical role, and when the person is closer to you. A reminder of why good communication between the team, patients and their families is important.

Prestige

Towards the end of high school, we flipped through a huge phone directory sized job guide, which has now become fully electronic. Abattoir worker, actor, aerobics instructor, agricultural engineer, analytical chemist, anthropologist, archaeologist. We have barely begun in covering the range of jobs starting with "A". By the way, anthropology was the one that sounded the coolest at the time. Oh well, maybe I will go back and do that BA one day.

At that time, I couldn't understand why training as an apprentice chef, was considered a "lower" job than say, an accountant. Or, why three years of university education was considered so much more worthy than a three year TAFE course. Or, why was it that, the higher a score that was needed to enter the course, the more students wanted to get into the course. Again I thought about the question, whilst working as a kitchen hand, alongside those who were a similar age to me, most who did not attend university, and many who did not complete high school. But, if you work hard at what you do, contributing to society in a meaningful way, what does it matter what you do? Even now, I'm not sure I completely understand the way our society ranks different occupations and careers.

In the same way, I don't understand why medicine is so prestigious. The expression of respect, especially but not exclusively within Asian circles, that becomes evident when one hears that you are studying medicine. Wow, you must be really smart. Uh, thanks? Not infrequently, I have had others misinterpret "studying medicine" to mean that I am going to be a nurse, or a pharmacist. It's when I feel the twinge of irritation of, no I'm going to be a doctor, that I realise, I have also adopted the attitude that we are smarter, better and simply superior. We joke about this so often and perhaps, one by one, we really start to believe it, if we didn't already upon entering medical school.

Elitist. Being in an old and well established university, our students are known for being stuck up, often making snide remarks about the incompetence of students studying on the other side of town. What, you are at a rural hospital for clinical school, you couldn't possibly have chosen to be there. Where are you going next year? Congratulations on your internship destination, largest is the best, the hardest places to get in, so you must be really good! Er, no I'm not, how do I explain that neither my marks nor my life achievements are amazing. I feel uncomfortable that my extended family is more excited about my internship destination than I am - uncomfortable, because I know they are happy because they love prestige. Anyway, how does older and bigger automatically equate to a better place to work and grow?

It just doesn't stop here. Which specialty training program are you in?  The enthusiastic "wow" for someone on the R.O.A.D. to happiness (radiology, ophthalmology, anaesthetics, dermatology), or training in a much admired field such as neurosurgery, is such a stark contrast to the "oh" someone training to be a general practitioner often receives - oh, why don't you want to specialise? Just like when we were in high school and choosing what to study in university, we equate more "difficult" entry requirements, to a better specialty, and a better person. Not just academically, but smarter, richer and more important. Therefore, we treat them with special favour. Or should we?

Good marks and hard work are fine in themselves, and indeed, many of those in highly sought after specialties are talented, committed, and deserve the respect that they have. But it really bothers me, the obsession of prestige and achievement that surrounds this profession. How across every level, from medical students to consultants, we are judged, and in turn judge one another, based on rank, specialty, place of training and other such criteria. Not only professionally, but just as much in personal and social interactions. And how we judge those outside medicine to be just... well, not as good. Why aren't you dating someone in medicine - or conversely - of course my parents will be happy with my sister's new boyfriend, he's going to be a doctor!

Perhaps, most troubling, is when this occurs in fellowship. Attending a medical Christian event over the weekend, we were asked to add our year level and university, or specialty for graduates, to our name tags. I thought, does this really matter, and pondered whether it would affect the way we talked and interacted with one another. More than a year ago now, I attended a talk at Christian medical event where I clearly felt the hospital hierarchy in the room. I happened to be seated next to registrars who seemed to want to make it clear that they were registrars (not intern or residents), and seemed to change their manner when they talked to fellow registrars, and when the medical students talked to them. Or it could be purely my interpretation; or, they were shy and not very talkative anyway.

The speaker in front was the head of the endocrine unit at this hospital, and the director of that very prestigious specialty college. During the talk (on a topic which I have now forgotten) I wondered whether at times the speakers were not speaking more as consultants to their junior doctors, on how to do medicine and life, rather than humbly sharing God's words and God's work in their own lives. Considering how important connections are, in turn, I wondered how many students were using refreshment and mingling time as career networking opportunities, rather than seeking genuine fellowship and spiritual growth. Maybe I was being over cynical, but certainly, the thought of focusing on the networking aspect did not escape my mind.

So in Christ Jesus you are all children of God through faith, for all of you who were baptised into Christ have clothed yourselves with Christ. There is neither Jew nor Gentile, neither slave nor free, nor is there male and female, for you are all one in Christ Jesus. - Galatians 3:26-28

At work, we should respect those in authority, including brothers and sisters in Christ. However, it was disappointing to see hospital heirarchy, reinforced by junior and senior doctors (and students) alike, permeating into church life and ultimately, hindering fellowship and taking the focus away from God. Recognising that we are all sinners, and recipients of God's grace, why should one (no matter who they are in the medical profession) exalt themselves over another? Perhaps that experience made me reluctant to join the medical fellowship events in M. Until recently that is, when I was once again reminded of the importance of being inspired by, encouraging and being encouraged by other Christians in medicine. Just as those who are proud stand out, there are of course, many who are marked by faith, having lives which point clearly to God.

Do nothing out of selfish ambition or vain conceit. Rather, in humility value others above yourselves, not looking to your own interests but each of you to the interests of the others. In your relationships with one another, have the same mindset as Christ Jesus: Who, being in very nature God, did not consider equality with God something to be used to his own advantage; rather, he made himself nothing by taking the very nature of a servant, being made in human likeness. And being found in appearance as a man, he humbled himself by becoming obedient to death — even death on a cross! -
Philippians 2:3-8

What's wrong with being elitist? What's wrong with loving prestige? What's wrong with having an elevated view of our profession, our university, our hospital, our specialty, our rank? It matters what we value first and foremost. We lose perspective when self becomes bigger and more important than God. We forget who we trust in, who we should be thankful towards for all that we have. We compare with others, begin to focus on collecting trophies, aiming for what is "best" and most prestigious, to serve our pride and desire for recognition. In doing so, we lose sight of our purpose, and become distracted from working for God, and living to love others. Jesus, king of kings, did not exalt himself but came to serve. How each of us, not least myself, should be constantly reminded to do likewise!

The game

This game has come to an end.

After my last interview, I realised all that I learnt during this game. Thinking about it, I played the game not only for the month of applications, but for nearly a year. Preparing to enter the game - having just that extra bit of motivation to nudge you over the edge to be involved in university life, be part of a committee. Laughing with friends about being the founder and president of a "evidence based CV padding committee". Checking out what the fuss was with conferences. Doing that interesting (or absolutely useless, but free) course, dabbling in some rudimentary textbook editing. It has certainly made our lives colourful.

Who would have guessed that the game would enhance my skills in being female. Preparing for that day, I figured out, for the first time, how to use a blow dryer and straightener instead of relying on waking up to find the hair tame and smooth (which it almost never is). Feeling the same way as I did when I was seven and smearing mum's eyeshadow all over my eyelids, as I bought some of these goodies myself and tried to apply it without making myself look like an evil witch doctor. My wardrobe had expanded in variety and volume thanks to days of shopping for a suit jacket but instead, coming home with bags of op shop bargains. Realising, it's perfectly acceptable to not to buy that $300 dress from Cue or Jacquie - an outfit that's "me" does so much more than one that's incredibly high class and out of my price range. Realising also, it's okay to not wear a new stunning pair of heels if you can't actually walk without falling over in those heels.

The interviews themselves were worthwhile. Recalling difficult times, mistakes, conflicts and smiling as I thought, wow, without these, there would be no real experiences to talk about. Forced to think of my future pathway, and having a wide eyed moment as I saw how paediatrics lined up with everything that I've done, from my family life, to holiday work, to medical electives and conferences (still undecided though). Preparing, I found was impressed with how articulate, clear and incredibly helpful you could be, making up answers for me because you knew my life experiences, my interests, my strengths and weaknesses.

Not having an interview at hospital 1, I realised that even games can hurt, and learnt to deal with the inevitable feeling of rejection. In hospital 2 I made some difficult decisions to practice self care, and discovered the affiliation I had to my university in ways I had not previously imagined. Hospital 3's group interviews were, well, different. Watching how each person presented themselves, and how each person walked the delicate balance between presenting well and being fake was remarkable. During hospital 4's more conventional individual interviews, I was pleasantly surprised how much more comfortable I was talking about myself in front of strangers, rather than practicing with my friends. Hospital 5, for you only did I write a completely sincere and heartfelt cover letter.

The game helped us to quickly see who our true friends were. Who you could easily share your successes and failures with, and which ones trusted to share theirs with you. Who happily told you the specific questions they were asked at their interviews, and who quietly slipped out of your life or gave a generic answer when you asked them how everything was going. I quickly realised for which friends I could turn from being envious to genuinely being happy for them, and for whom I had real difficulties ridding myself of poisonous feelings towards them, because I honestly did not like them. Being busy also helped to weed out friends of convenience to friends who make an effort to meet up - after all, if you never see or talk to each other, what sort of friendship is that? Being busy, I realised also that I rather enjoyed being productive, having a routine, doing something, rather than the nothing-ness of the previous semester.

Making these decisions, I learnt to communicate to my family about matters which I felt strongly about, and at the same time, being more receptive to their suggestions about matters which I felt ambivalent about. Waiting for the outcome, I knew clearly that walking with God is many times more important than where I will be next year. Finding out the results, I'm learning to have the proper perspective of being thankful, rather than proud, whether openly or secretly. I called it a game, not because I feel that I can go wherever I want without trying, but because all along until now I have no strong preferences of one place over another. I had participated for the process of playing, rather than the outcome, and it was worthwhile (for the process, rather than the outcome).

East and West

Comments - I've been told again over the holidays that comments didn't work properly, changed the settings, hopefully it's fixed.

I've been spending much of my days in the Western suburbs recently. We've gotten used to the many skin colours, the gangstas, the drop outs with numerous piercings, the psychiatric-looking, the IV drug user type of people on our trains. Then the suburbs with hardly any landscaping, plain gardens, surrounded by old rundown factories and train stations where people are stabbed and robbed (which fortunately, hasn't happened to one of us yet). The cheap markets, and dingy untidy food stores, narrow streets and foreign signs everyone making the suburbs look like you've just been transported to Asia. Well, the food is fantastic. Yes the only thing I miss about frequenting that hospital, is the banh mi and pho (oh indeed, in these posts food is always the ray of sunlight shining through the clouds).

I've never properly been aquainted with the Eastern neighbourhoods. Although I've been at this hospital before, I was amazed at how hilly, how green, leafy, scenic, lovely the houses and neighbourhoods were. Walking to my friend's car, we saw young Caucasian mothers pushing their babies, and fit retired men going for a jog, instead of some smelly, shaggy looking dude, snarling at his equally unkept wife and slurring his speech as if he was drunk. We walked past massive frontyards which had a steep rise like a small hill, or the house was tucked so far back in that we could not see the front door from the driveway. The houses themselves were huge, and old, but with character. Instead of old and boring, or old and rundown. The streets were wide instead of narrow with cars parked on each side (pretty sure it's because people have enough space in their own houses to have garages for their fancy cars). The greenery on both sides were tall, majestic, and I wondered whether they skim on spending money to plant nice trees in the Western suburbs. Even infrastructure including highways and streets are better, less congested. I think the roads in the West need major restructuring considering the huge population expansion, and new suburbs that have opened up.

Even the most beautifully renovated house in a dodgy suburb would not have quite the same feel as a very average house here. So, that's what what you pay for when you buy properties based on location.

It's funny really, in Singapore, I've hard some pretty strong opinions of the "Eastern" residents about how dirty, industrial, unpleasant, the West side was. Come hang at the Westside yo. You know the novel North and South? Such a rigid division of the idyllic farmlands, cultured citizens, and the polluted, rough, factory regions. Maybe it's time to write the book "East and West", any takers?

Essentially, it's the inevitable divide between the rich and respected, and the poor, the less educated, the outcasts of society. I mean, why would you not rather lovely neighbours who fit in your social circle, and can be trusted in helping you keep an eye out when you're away, rather than the neighbourhood always attracting police attention because of teenage drug users and domestic violence issues.

And it makes me wonder, where would I live? Or rather, how would we respond if God asked us to leave the life that we imagine ourselves to have (the typical income, house, status that usually come with being a doctor) in the future?

(Rich young man story) "One thing you lack," he said. "Go, sell everything you have and give to the poor, and you will have treasure in heaven. Then come, follow me." At this the man's face fell. He went away sad, because he had great wealth. - Mark 10:21