What I think about during clinic - part three

5. Children

Children are often such a clear reflection of a stable, or dysfunctional family. A little girl with neatly brushed hair and clean clothes, comes in coughing, politely covering the mouth with hands or elbows. Her mother is educated, concerned, but not overly anxious. A young boy comes in, with his alcoholic mother and father who can't keep a job because he often doesn't bother to rock up for work. The mother warns the doctor about how he may swear profusely whilst the local anaesthetics injection is being administered.

There are patients who really struggle with life. Then some have kids, and lots of them. It's stressful because sleep is disrupted, the kids need to be ready for school, somebody needs to care for them when you are at work, kids get sick frequently, and so on. If parents are barely managing to care for themselves, or have one unstable marriage or relationship after another, you can't help wonder, why have so many children? (I wonder sometimes for myself too, whether I have enough mental stability to be a parent.)

On a brighter note, I'm almost always more awake when I see a child. It doesn't matter what they come in with, even if it's URTI after URTI. I don't tire of playing peekaboo twenty times in a day or sticking my tongue out at the child (only if the doctor and parents are busy talking to each other). I'm happy to lend my stethoscope as a toy. I remember how five year old C always loved to listen to bowel sounds, then would pull up her own shirt and say with a sweet smile, "do you want to listen to my tummy?" Sometimes I want to pick kids up for a cuddle but I guess that's not really part of the job of being a doctor. I did once though, and quickly realised that I should be careful with my dangling earrings and hair that isn't tied back, as naughty little babies pull at anything they see.

For years I've always said that if I wanted to do paediatrics, I might as well have done veterinary science. Like pets, children are uncooperative, plus they scream, growl, vomit and even bite you. Before my children's rotation earlier this year I had the following conversation with C.

C: Children's hospital (reading my rotation timetable on the computer screen). Do you like kids?
W: No.
C: Aww, but you like me!!
W: Yes, but I only like you!

I guess that's not so true. Although C, I only like kids because you're such a beautiful, lovely, bright, happy, funny, little girl. I only like other kids, maybe because I really miss you when I don't see you for months and months.

6. Aging

When a child pouts and throws a tantrum, or lacks insight, it's acceptable. But in a full grown adult, or elderly patient, it's distasteful. Even if the maximal mental and emotional capacity in that person, is the same as a child's. Life's not fair, is it?

The circle of life is a running theme in general practice as you see children, teenagers, young adults, progress through stages of learning to walk, run, work, drive, live on their own, be married and have children. And in the same room you see the elderly, gradually becoming unsteady on their feet, losing their memory, unable to drive, being widowed, needing to go into care because they are no longer coping. An interesting medical interpretation of Ecclesiastes from a fellow student, which made me laugh when I heard it:

Ecclesiastes 12:3-5

...when the keepers of the house tremble, (unsteady hands)
and the strong men stoop, (kyphosis)
when the grinders cease because they are few, (less teeth)
and those looking through the windows grow dim; (sight)
when the doors to the street are closed
and the sound of grinding fades; (can't remember, stopping work?)
when people rise up at the sound of birds, (insomnia)
but all their songs grow faint; (hearing)
when people are afraid of heights
and of dangers in the streets; (fear of falls)
when the almond tree blossoms
and the grasshopper drags itself along (impotence)
and desire no longer is stirred...

From dust we came, to dust we return. Entropy, sickness and death overcomes all. And seeing that each day in clinic is unsettling and frightening, knowing that neither I nor the ones I love, can escape.

(continued from Eccl 12:5)
...Then people go to their eternal home
and mourners go about the streets.

But seeing life and death is also a constant, and perhaps a much needed reminder that this is not home. Which forces us to reassess how we're spending our short life, and about exactly what we're chasing. I fell in love with this song when I heard it for the first time recently, on the way to clinic:

...Cause what if your blessings come through raindrops
What if your healing comes through tears
What if a thousand sleepless nights are what it takes to know you're near
What if trials of this life are your mercies in disguise?

When friends betray us
When darkness seems to win, we know
That pain reminds this heart,
That this is not, this is not our home
It's not our home

What I think about during clinic - part two

3. URTI

URTI (upper respiratory track infection ie the common cold/coughs/sore throats). URTI. URTI. URTI. Repeat script. URTI. INR. Script. URTI. URTI. URTI.

"My throat is really dry and sore. I feel yucky and cough up this really gross... stuff." The patient would pause for dramatic effect and frown in disgust. Perhaps not realising that the doctor just heard this twenty times that morning and has switched into autopilot mode.

"Look, there's no temperature today, your throat is fine, ears are fine, lungs are clear, it's a probable viral infection and should just clear up by itself in a few days. Plenty of rest, fluid and Panadol. Wait, oh, I didn't check your throat yet." I giggle silently and think, I knew it was a scripted response!

(By the way, doesn't it make you feel uncomfortable to think that the bored medical student, sitting at the edge of the examination bed, gazing out of the window, half reading a handbook, stifling a yawn, is quietly but surely observing and critiquing each word and action, and maybe even sensing your feelings and thoughts during the consult? I think I would feel quite self conscious if the roles were reversed.)

Instead of typing the same notes again and again, slowly with your two finger method, why not use a copy paste template for URTI notes? Would it not be better use of a doctor's training and health care resources to have URTI clinics run by community nurses? Only problem would be that occasionally, the presumed minor illness may be the start of something more serious.

OHCS makes me laugh. In regards to minor illnesses the first paragraph reads "...GPs do not have a sufficient monopoly of this to justify being called 'triviologists'"

4. MC

The only reason many URTI patients go to a GP is for a medical certificate (MC). Several weeks ago, if not for that precious piece of paper, I wouldn't have driven in a half awake state, waited in a clinic (not for very long), and have a (very lovely and comforting) doctor diagnose something that anyone off the street could diagnose.

Whilst medical certificates are probably needed for year 12 students who are unable to sit major exams, or for prolonged inability to attend work due to a more serious medical condition, our society seems to be obsessed with them. A seven year old child's mother asked for one because the swimming instructor required a medical certificate for non attendance. Surely for primary aged children, a note or explanation by a parent is sufficient.

It's as if schools, organisations, workplaces assume that a doctor's signature automatically makes an illness and off days legitimate. Which is untrue. If you're keen, it's easy to fake symptoms. Even for an URTI the GP decides arbitrarily how long you should rest for - maybe a day, maybe a week. Regardless of whether you offer a convincing story or not, if you visit the right GP, or enough GPs, you will find someone to happily print an MC for today's, or even last week's illness - if you're lucky. The huge emphasis on producing medical certificates for everything means that GPs spend large amounts of time on unnecessary paperwork, rather than clinical medicine. Again, poor use of health care resources.

What I think about during clinic - part one

1. Typing

"I hate not being able to type properly. It was such a disadvantage during the fellowship exams. I took double the time. Could hear all the other candidates tapping away..."

Touch typing should be compulsory, my classmate commented. The variety you see is amazing. Hunt and peck, with one or two fingers, index or with the middle finger. Or even touch typing with the left hand but pecking away with one finger on the right. Okay, if you're eighty and coming to the end of your career it's not so important. But for everyone else in the practice (doctors, nurses, receptionists) this should be part of professional development. Think of all that time you can save.

At least medical students can be helpful in something, eh? Typing out notes as the clinicians dictate, or helping a nurse to discover, with much delight, that keyboard shortcuts exist for copy, paste, underlining, and bolding text.

2. Consent

Being a female student, I didn't have a single patient refuse consent for a long time, even during the rather awkward gynaecology clinics. But there seems to be an average of one patient each day at this clinic who refuses to see students simply on a whim. Or the patient who comes to the appointment half an hour late and writes on the form:

"Student okay, but wants doctor to do everything." For a straightforward cough and cold. I don't think the person realises that although less experienced, students are taught to be thorough. And even the doctor is more likely to take less shortcuts, and think properly about your case, when he or she is teaching.

I'm happy to sip hot tea and milk in the tea room, munching on an apple or the occasional pumpkin seed, surfing the net on my phone. But whilst waiting, I also began to form strong opinions about consent in regards to seeing medical students.

Firstly, it all depends on how consent is obtained. Some sessions I get a run of several patients refusing consent and I can't help wonder what the reception staff is saying to the patient. No wonder some of my male classmates had difficulties getting into delivery suite when the midwife, with a frown, said tentatively:

"Well, there is this male medical student... would it be okay if he attends the birth? You can say no, it's okay to say no..."

Scenario one - written consent needs to be obtained for every patient (as it is in this practice). Scenario two - displaying clear signs in the waiting rooms that this is a practice with medical students, and if patients have an issue with having one in their consultation, they can speak to reception to opt out. I'm sure the number of patients who say "no" would differ. A lot.

Coming to the end of my time as a student, I can't help think, well in a few months time I can't refuse to see you in the emergency department, in outpatients clinic, simply because I don't feel like it. Certainly, a patient should be able to opt out of seeing the student if there is a legitimate reason - for example, if the student was a family friend and the patient needed a sensitive examination, or wanted to discuss serious mental health issues. Or if they need to be somewhere by a certain time, and can't be in with the student for half an hour before the doctor sees them. That's okay. But it shouldn't be for no reason.

General practice

Throughout these years, I don't know how, or who is responsible for this, but more or less we all have a picture of the general practitioner really knowing their patient and family, talking in depth with them not only about the physical ailments but having abundant time to explain results and addressing their concerns. An epitome of work life balance, family friendly hours, and just a healthier working environment than hospital medicine.

Week one and two. In, out, in, out, an endless list of patients, one after another. I don't see how there's more time in these clinics than a public general medicine or surgical clinic. I don't see how churning people in and out, quickly dishing out the necessary paperwork, scripts, eyeballing a wound, performing a quick minor procedure, is any less fast paced than working in the emergency department. Consulting at a rate of six patients per hour for the entire day, skipping lunch, working until the sun sets, isn't my idea of work life balance. But it depends who you sit with, and clinicians do choose their working hours. Unfortunately they don't allocate medical students half days.

Seeing so many within a short span of time, I have noticed something completely new, and unfortunate within myself. I get sick of people, sick of talking, sick of engaging in small talk, and especially talking behind a mask, a persona. The time waiting for the doctor to finish with their patient before entering the room is agonising. It's the training grounds for random chit chat. Of course I love what I'm doing, of course I'm enjoying my rotation, of course graduating soon is so exciting! I muster up an unusual (and if you know me, unnatural) enthusiasm and smile; oh, how could I answer otherwise with those genuine smiles and innocent eyes looking at me expectantly?

"Do you want to specialise in anything? Are you planning to study after graduating? Or just be a GP?"  Do general practitioners get tired and frustrated with the public perception that somehow specialists are GPs but more senior, more qualified?

Then I tune out, and spend more time typing away into the computer program than listening to what the patient is saying. Which doesn't look as rude as it sounds, because I am simply imitating some of the clinicians at work. Never mind that I actually disapprove of this. It's just easier, mentally, to float in and out of the conversation. At times, I know without patients saying outright, and without asking, that they have a particular topic they want to discuss, which was the real prompt for their visit today. The underlying concern which we were always taught to ask about and address. But I ignore what I sense because I don't want to talk, or be engaged. Sometimes during the consultation, I feel a tug of guilt and am prompted to turn around, face the patient, lean closer, looking at them, and ask "how is that headache?" But the rest of the time goes something like this. Sorry I don't think I will be a very good doctor.

"Yes well, I had the sore throat and two days later I started the cough."
"Sorry, when did you say you started coughing? Did you say you had a sore throat?"

"I catch up with the doctor every few weeks or so. Just to update him on how I'm going." She said elusively, as I asked her what she was in for today. I've always been the last one to dismiss "health practice" and "ethical practice" as useless arts subjects, or scoff at a patient's multiple psychosocial issues. But perhaps the sheer ratio of non-medical to medical cases strains on my ears, and my sympathy.

He's a charming man to be sure, just the right dose of intelligence, wit, friendliness, and warmth. By the way, the doctor goes from being your standard doctor doing a conventional shoulder exam, cutting out skin cancers, to one who wields acupuncture needles from head to toe, blows a small piece of charcoal and places it on a woman's abdomen to focus the energy, or flicks muscle to work with fascial planes. He knows better than I know that they're not coming for healing with conventional medications, and not even the alternative medical treatments he offers. That afternoon there were a whole string of mostly female patients who were, I'm sure, drawn to something about being able to talk to someone, anyone, about their week. Being cheered up, and having their aches and pains magically fixed by a smile and a positive energy. Someone to flirt with, even if it's done within appropriate social bounds.

What a lonely society it is, an African doctor had commented. I agreed. The idea of a big fat Greek and Italian families, the classic Asian culture of filial piety, or the necessity of having many family members visit an Indigenous patient at the hospital is often ridiculed. Living with extended family members, or supporting and living with aging parents is often seen unfavourably, an intrusion, in an individualistic world. Yet the freedom and self sufficiency our society encourages comes at its own price. Since when has the doctor been the first and best point of call for emotional and social issues - at home, at work, with children, with spouses, with in-laws? For sure, we should be sensitive to those issues and there is a time for pills and treatments. But it seems that some people see doctors as an automatic solution, a healer mystical powers to charm away the weariness, pains and sufferings of life on Earth. I wonder if we roll our eyes and groan at "non-medical" presentations, not only because we are not called to utilise the little ability we have in aiding physical illnesses, but also because we are baffled at the enormity and impossibility of being a healer for the emotional and social sicknesses of our world.

I have a terrible attitude, and I don't mean to be so negative. I had always loved clinics, and had waited in anticipation for this rotation. I am trying to find some positives. The doctors are nice and I even came across an old friend. The endless supply of mixed dried fruits and nuts, simple stocks of tea, coffee, fresh fruits, bread, tuna, cheese, milk and crackers is absolutely delightful. I am really only less than ten minutes away from the clinic every morning. I could even nap for an hour every lunch time, but I don't. Putting clinical skills and the knowledge we've gained over the years into something useful, is good. Finding out that I can't suture neatly is, not so good. Children are adorable. The town is one of my favourite places, exercising here and only here is fun, fellowship is refreshing.

But I'm resentful. For the ringing of an alarm clock. For not having enough time to do all the things I planned to do after last semester was over. For being kindly lent the textbook but not having the opportunity to open it. For wanting to switch off every time I come home, then indulging too long in the world of my novel, and paying the price with not enough sleep. For having to quickly whip up a simple dish instead of cooking something which makes my eyes and heart light up. For leaving most days when it's too dusky to hit a tennis ball accurately, and becoming too dark to enjoy a walk around the beautiful swan filled lake. Not being able to sit down and write out these thoughts though I've been itching to do so since I started the rotation. Let alone create new posts for the food blog.

I hate it. Not general practice itself - I haven't crossed it off my potential career pathways list. But because I feel trapped, like a rat (any creature really, just arbitrarily chose my favourite), wearily then angrily pawing at the confines of its cage. I'm turning into a monster with evil red eyes, sharp claws and bared teeth. Worse still, knowing that the confines will only grow smaller, have less breathing space, be more inflexible, as this year rolls onto the next. It's frightening. How can you run, run, as fast as you can? And where, oh little rat, will you run to?

Multiple sclerosis

I am reading about the disease and thinking about the long case I did today. Just as the intern promised, he was the nicest patient. We talked about the multiple sclerosis, and how he coped at home. Sitting there he looked fairly well.

Then when the physiotherapist came and asked him to do some exercises, I suddenly realised how debilitating the disease was. The slow unsteady steps of an otherwise healthy, middle aged man, in walking down the corridor. The stiffness of the affected arm, and inability of the fingers to open or close. The immense difficulty in moving from the chair to the bed, lifting the entire weight of his "buggered" leg with his good arm, then the difficulty again in getting out of bed. I would prefer an amputated leg (below knee though). It's hard to appreciate the convenience, in us who have four working limbs that move the way we want them to.

We discussed multiple sclerosis earlier on, how its progression is scarily unpredictable. How it doesn't really get better - even some cancers have the potential to be cured. It's great though, that there are medicatiions to slow the progression of disease. At least this man sounded like he had a stable and supportive relationship with his wife and grown up children. Compared to other patients with multiple social issues - with questionable partners, being parents of young children, those who had mood issues along with their physical illnesses. Having family members around, and being connected with people who care is so important. Seeing the key role of spouses being the carer for so many of the patients we see, we often joke about  how important it is to find someone who will honour their marriage vows - in sickness and in health. I guess that also often makes us reflect whether we would be able to take care of our spouse if they had a serious chronic condition. It's so easy to say when you're in love, isn't it?

Side note: whilst looking up "vows" I came across Vows Now, wow there's all sorts of interesting stuff. Short three minute ceremonies and if you want, everyone including the celebrant will wear fancy dress party themed costumes...

Circle

I know I've been writing a lot about aging... this is the last one for now!

A lot of us a repulsed by the idea of getting old. Incontinence, disinhibition (eg. socially inappropriate behaviour), immobility. Children don't have great bladder control, they do and say inappropriate things, and young babies aren't exactly mobile. Aging is like reverting to childhood, with limited memory, reasoning, abstract thinking.

Why do we find the same qualities so adorable in children and so devasting in elderly people? Why do we willingly look after babies, no matter how messy and naughty they are, but find it difficult to do the same for elderly relatives?

There are differences though. To have had that independance once, to have had that mental capacity, that ability to interact meaningfully with friends and family... to lose what you once had is quite different. Besides, babies grow out of it; to see children gradually attain physical, cognitive and social growth is one of the greatest pleasures of being a parent.

There was a time when I woke up early to see sunrise. I was shocked by how glaring and bright it was compared to the many sunsets I've seen. Mum commented that birth and death is similar. Indeed, babies enter into the world crying with all the might they can muster, and many elderly people slowly and quietly slip away.

Entropy - 2

It's inevitable. Your muscles start shrinking, bones undergo microfractures, the lens of your eyes gradually become thickened and the colour changes from clear to milky. Half of your smell and taste sensations are gone, the most mouthwatering dish becomes bland, ice cream is no longer sweet.

Even with the most careful diet, even without the risk factors of obesity and smoking, your risk of getting diabetes steadily rises. So does your blood pressure. Hypertension. To coronary heart disease, glomerulosclerosis, stroke.

Gradually your memory slips away. And you forget who you are. Even if you recognise your loved ones, you no longer feel a connection with them. Can't quite comprehend how they became, and how they are your children, your spouse, your sibling.

"Aging. And the only way you can avoid it is to die".