This month in the student BMJ

This month's sBMJ had two articles that particularly sparked my interest.

Firstly "People with disabilities face barriers to healthcare"* - a brief article on the first World Report on Disability produced by the WHO and the World Bank. Fine, it's stating the obvious, but even what's included in the wee article seems to suggest that the report will be worth a read. I'll give you my thoughts in a few weeks.

The picture alongside the article however (I'm not sure if it's from the report or not) is the standard wheelchair-user-disabled-logo, pictured at the bottom of a flight of stairs. It's strange because as you'll see if you follow the link, the cover picture is a blurred background with a hand holding the top of a white cane in the middle - quite striking, and not 'predictable'. (There's also an article in the grown-up BMJ, but I don't have an Athens account these and I've forgotten my BMA log-in, so I'll have a look at it later) It's interesting that they've used the phrase "people with disabilities", rather than "disabled people", as the second seems to be more then norm in the UK (I'll explain the difference at some point) but I suppose it is an international document.

(Incidentally, if you're tired of wheelies being portrayed as lifeless, genderless, boring symbols, check out Hannah Ensor's website Stick Man Communications - Hannah is a wheelie herself, and has a huge talent for showing the joyful and ridiculous side of disability. And she's a bendy like me!)

There is another article called "Under Pressure"**, about stress / mental health problems in medical students. It's really quite good - thoroughly outlining the situation, but also offering some examples of good practice under the heading "Preparation and Prevention". I'm really pleased with it. It outlines the spectrum of stress-by-high-pressure, to 'clinical' mental health problems, and deals with the issues surrounding both. This issue is really important, and I don't believe it is dealt with sufficiently at most medical schools. It would be great to have other articles of this quality on other aspects of health and disability specifically for medical students.

All in all, big thumbs up. Both articles managed to penetrate the current brainfog, which is an achievement in itself.

*BMJ 2011; 342:d3618 (this is the citation it gives, confusingly enough)

**Student BMJ 2011;19:d3678

What's all the fuss about?

When I had a meeting with the head of my year in the medical school this year, he kept saying things like "I think you're being over-cautious, you won't run in to any problems" or "doctors deal with patients with disabilities so they're good at dealing with colleagues with disabilities". I couldn't get through to him that it wasn't that I was worried in case their would be problems at some point in the future, I was there because these problems were part of my daily experience.

So I decided to keep a list of all of the accessibility issues I encountered during one day of placement this week. Obviously things change between hospitals, but this is a fairly average representation.

1) There are 3 steps up from the front door to the entrance hall. There is a level entrance door, but it's not right at the front where I can get dropped off, and it's the other end of the hospital from the paeds ward.

2) The lift buttons are incredibly stiff, so I either sublux my fingers or don't manage to register that I've pressed them every time. I eventually ask a stranger for help.

3) The ward has a keypad entry system, and push button to exit system. If I have one hand on the stick, and one on the keypad, then there's no hands for the door. And the period the door is open is very short so I keep missing it. A nurse takes pity on me and comes to open the door.

4) Once inside the ward, the doors are big, old, fire doors. I can only open the push ones, because when I try to pull them open, my joints give before they do. Again, a nurse helps me out. I would not manage at all in a chair. I'd tip over.

5) The doctors room is not on the ward, but is as often happens, at the other end of the building. This means longer walks backwards and forwards, which add up really quickly to increase pain and fatigue. It also means getting through a tonne of the above heavy doors of evil.

6) The ward has very small cubicles. Each has a bed / cot in for the patient, and an armchair bed for a parent to stay. When there are two doctors, a nurse, and a parent in, there is barely room for me, let alone for me to bring a chair in. By the end of ward round at the start of the week, my seated heart rate was 150.

7) There are very rarely (if ever) staff disabled toilets in hospitals, and this is no exception. I use disabled loos because it saves me getting stuck not able to stand up (as nearly happened in the cinema yesterday). This is an infection control and privacy issue, and often means having to leave the ward and going to the ground floor to find the only appropriate one, especially in a small old building.

8) The toilet door is heavy. The lock is stiff. I nearly can't get out, and there is no alarm cord with which to summon help (not that they're generally heeded anyway).

9) The shortcut from the ward to the dining room involves going down 2 flights of stairs and back up 1, then the same in reverse. This is how the others go to lunch, but I have to go to the lift, and people ask why, and it ends up being a really obvious difference. Consultants also tend to not think before run down 5 flights with a teaching group, too quickly for me to ask where it is they're heading.

10) The canteen is self-service. I asked if someone could carry my tray to the table, because my wrists are prone to giving way, even when one of them isn't taken up with stick. The staff refuse, because it's busy and they "don't do that". The consultant comes over and takes my tray for me, and goes off into a reel of "you're so brave to deal with this" nonsense. I'm not brave. I just get up in the morning and live my life.

11) The consultant was late for clinic, so I had to stand around and wait for him, because the few chairs in the waiting room were full. There aren't enough chairs in the world in general, I've decided.

12) Spent the whole afternoon in clinic during which the consultant took no rest breaks, so as a consequence I didn't either. 4 hours of near constant sitting in a chair without arms means that I have a wicked headache / neck spasm by the end from trying to hold my head up. It's increasingly hard to concentrate.

13) In the clinic, the examination couches were fixed height, so it was not possible to sit down to examine the patients.

14) At the end of clinic we were taking a pile of case notes up to the secretaries. Case files are heavy, even in paeds, and the fastening are stiff and awkward to use, causing more hand trouble. (The delay in getting paper letters out really disadvantages coordinated care, especially for kids with complex conditions. They're currently typing up letters from January clinics). Junior doctors spend a lot of time acting as postmen for Xray requests, and case files.

14) I get a lift home, as I got a lift in, for which I'm very grateful. The bus stop isn't within my walking capacity from the house, and the bus stop outside the hospital is at the bottom of a steep hill leading up to the entrance (as seems to often be the case).

15) In the middle of this I am trying to keep to a good routine for my meds, and food, because my tummy's been so sad recently. This is really hard when you're not in control of your own timetable.

This is one day of placement, not including what happened before or after at home. It gets very tiring.

Cheerio 4th year

My year ended in a really positive way. 6 months of placement without a break had gradually worn down my self-confidence, my motivation and my health. I spent a lot of time wandering whether it would be worth it, and more time worrying that I would get so run down that I would have to take time out. In my uni if you take time out you have to complete the whole year again from the beginning, rather than slotting back in at the point you left. I just had this nightmare vision of getting to 3 weeks from the end of the year, getting sick, and having to do the whole thing over again.

The last hoop to jump through of the year - getting signed off in my last placement by the supervisor - went remarkably well. It involved a neuro exam, something that I had been really shaky about until the start of this year, and until the start of this placement i hadn't really known what each part of the exam was looking for with any certainty. I felt really proud when I managed to complete a thorough, slick examination, and to answer all of the questions afterwards. This year has been really difficult, but it's such an amazing feeling to look back and realise how much I've learned - especially how much stuff that I vaguely new before I have now understood and cemented properly in my brain.

One of the (many) things that I love about being a medical student is that there's always more to learn, and that most of it has direct practical applications. It is incredible that the human body doesn't go wrong more often than it does!

Highlights of the year include : picking up my stethoscope after a year of intercal, getting to manage real-live airwaves in anaesthetics - especially putting in an LMA, finally learning my diagnosis, a placement with the community addictions team, feeling a lot more confident on the wards than I did before intercal, rediscovering reading and last but most importantly, moving in with my partner, and getting a cat.

Written exams : the basics

To celebrate this being the first time in in 16 years that I have had no summer exams (other than an optional mock exam today), here is my exam survival guide. I hope you might find something useful hidden in the depths of it =)

The beginning of the year, or as early as possible :
1) Sit down with someone in the disability service +/- the medical school, and discuss any adaptations you might need. Remember to plan for your worst day. They will be able to tell you what kinds of adaptations they've made for other students. (For example, using a scribe, having rest breaks, or sitting the exam in a separate room)

Before that meeting it would be helpful to think back on previous exams, or to do a past paper in as close to exam conditions as possible, to find any problem areas.

2) Don't let anyone give you the excuse "but when you're working you won't (get extra time, for example)". You might want to say "yes, but it is not your responsibility to make adaptations for me in the work place". This is more relevant for clinical exams, and I'll discuss that another time. It's a tricky one.

Don't let anyone feel like you are gaining an unfair advantage. These are adaptations you need to minimise the impact of your impairment on your exam performance.

The month of the exam :
3) Practice using any unfamiliar adaptations, such as working with a scribe.

4) Learn a quick relaxation technique, and practice is, in case you have a blind panic on seeing the first question (been there, my friend). Some examples are lying flat on the floor and counting slowly to 100, contracting and relaxing muscles working from the feet up, and reciting a funny poem or singing all the way through your favourite song in your head.

The picture shows a window sill, on which are placed a
pile of books, and a big ball of wool with knitting needles
sticking out of it. Outside the window is a lamp-post.

The week of the exam :
5) Make like a marathon runner and tone down your study. Prioritise rest, good meals, stress busting (cinema, craft, coffee with friends, gentle exercise) and some gentle "dotting the Ts" revision. Get your sleep pattern in sync so it's not an effort to be up in time for a morning exam.

The day before the exam:
6) Make sure you know where and when the exam is, and how you're getting there. I get my Dad to phone the morning of every exam to make sure I'm up (not what you might call a morning person...) Give yourself the best chance of sleeping well by using good sleep hygiene (riciculous phrase!) +/- a wee dram.

7) Make sure you've packed the following in 1+ clear plastic bags :
- pens, pencils, rubbers etc
- uni ID badge if needed
- cushions, splints etc
- regular medication and any PRN you might need
- bottle of water (that you can open) and snacks (unwrapped and folded in kitchen roll so you don't rustle)
- lucky charm or something that makes you smile

The morning of the exam :
8) Wake up in time to have a proper breakfast and a drink and leave in plenty of time. Don't look at any work longer than 1 side of A4.

During the exam :
9) Take at least one 5 minute toilet break (if you don't have rest breaks) to stretch your legs, run through a relaxation technique and/or refresh with a snack. I tend to do this after my first plough through, at the switch between types of questions, or if I get a bit freaked out.

10) Think about variety to reduce over-straining any muscles / joints, and to keep your brain engaged. Switch pens regularly so you don't get the dread exam hand cramp, change sitting position (or switch between between sitting / standing / lying down if that is helpful for you) and consider not doing all questions of one type in a block, but rather doing half of one and then starting the other.

What pre-exam routines do you have? Have your med school been helpful in terms of exam arrangements?

"Cheer up love, it might never happen"

The last couple of days I've had a fever. That, combined with the marginally hot weather has really pissed off my malfunctional autonomic nervous system. I've spent the last two days with a seated pulse in the region of 120-150, temperature regulation all over the shop and feeling sick. I haven't been in to placement, being as fainting on patients tends to be frowned upon.

I decided to keep my hydro(therapy) appointment, because I hate wasting appointment time. I warned the physio I was having an "ultra-bendy" day, and he seemed to get the picture pretty quickly when both wrists, elbows, shoulders, patellas (patellae?), hips, and several ribs all needed relocating at least once. He said it was useful to see how bad things could be, which is good I think. But then I passed out climbing out of the pool, and had to do some fast talking to not end up in A/E.

Then on the way home, the bus driver didn't stop at my stop, even though I had rung the bell, and then rung it again as he obviously made to not stop. He let me off at the traffic lights because a lady shouted at him for me. This proved to be the last straw for my tear ducts, so I was walking forlornly back to the flat leaking from the eyes, prompting an it-might-never-happen attack from a passer by.

Had I been more coherent and less snotty, I would have been inclined to ask him why exactly he thought I was walking down the street in tears if "it" hadn't already happened.

I get extremely frustrated when I am discriminated against by people refusing to meet my needs, but I am not given to self pity. I would just like to get on with the life I find myself in, thanks. Not that I'm some kind of saint or anything. I've had a few I-just-want-it-to-be-easier crying sessions, but, actually, having a diagnosis at last has made things more cope-able.

What is this "it" to which he was referring? Yes, I am engaged to a beautiful, caring, smart and infinitely capable women, yes I am writing this with a blissed out cat on my feet eating a takeaway (no, my cat is not eating a takeaway), yes I have an education and the chance to do a job that I'm really passionate about, and the best friends and family I could ever ask for. Nothing cancels any of those things out, but I am also coming to terms with a new, life-changing diagnosis, and learning to cope with chronic pain and its friends.

There are worse "it"s, but this is mine, for now. And if you really want to cheer me up, I suggest providing me with one of the following : dark chocolate with ginger bits in, cherry tea, a hug, a hot wheat bag, a compliment on my awesome stripy stick, a new craft project or a vegan cookbook.

Edited to add : cherry tea and a hot wheat bag have just appeared in front of me, and a vegan cookbook is winging its way to us. I love my mrs =)

Unreasonable adjustment?

I've had a lovely couple of days doing a resus training course. I really enjoyed the content, and getting to know some more people in my new-since-intercalating year.

I had one particularly good conversation which started with a girl asking me "How are you getting on this year, because the stick's a relatively new thing isn't it? If it's not too personal?" We then had a really interesting conversation about the parts of the course that we both find difficult, as introverts. She seemed to instinctively understand, as well, the parts of the course that would be difficult as someone with a relatively hidden disability - such as always turning up in new places and working with staff who haven't got to know me, and therefore don't know that I wobble-and-fall-down if there isn't a handy chair.

She couldn't believe that the medical school (or rather some individuals within it) didn't share her common sense. To her it seemed as obvious as it does to me. As I have discovered, which will come as no surprise to some of you, on a personal level folk within the med school do understand. The problem is not that they can't see the issue, the problem is that they cannot see how to deal with the issue within the current way of doing things, and therefore pretend that the issue doesn't actually exist. It's incredibly frustrating, and humiliating - and, over time, leads you to question whether there is actually an issue, or if it's just you being unreasonable. Sometimes it takes someone else to state the obvious to redress the balance.

Has anyone made you feel unreasonable for requesting "reasonable adjustments"? How did you deal with it?

I've updated my links page into two separate pages, Disability and Medicine, and Other Disability Links I hope you find them useful.

Hooray for showers!

I had a meeting with an OT the other week. As is becoming the norm, she gave me a whole list of things that would be helpful for me, but said that they didn't have funding to give me any of them*. Except for yet another not-skin coloured brace, one size fits none. Then, she had a brainwave. We still have lots of bathboards in our budget, do you have any problems in the shower?

I used to love showers. A long, warm shower at the end of a hard day was one of my favourite things. But over the last year, it'd become almost impossible for me to have a shower in our current set up, with a shower over the bath. On most days getting in to the bath was about do-able, but climbing back out when everything was slippery was decidedly treacherous. Combine that with my propensity to faint at the sight of hot water these days, and my inability to stand still for any meaningful length of time, and you start to understand the number of bruises, popped out joints and concussions I accumulated.

The picture shows a white plastic bath board over a white bath.
The tiles in the bathroom (not mine!) are yellow and blue.

It had got to the point that I was showering maybe once a week, and only with a lot of help, swearing and the aforementioned bruises. Noone (not GP, rheumatologist or physio) thought this was a good enough reason to refer me to OT. I was referred in the end because I "bend my hands in ridiculously disgusting ways", to quote the physio.

Yesterday the bath bench arrived. It is very white (one of two NHS regulation colours, the other being not-skin-coloured) and a bit ugly, but hey. It will make transferring in and out my easier, and will mean I can sit down for most of the shower. Privacy, safety and cleanliness, all in one lump of white plastic. And all for like £30. And the mrs is pleased...it's a much easier way to shave your legs than trying to balance like a stork!

* Some really good ideas though - I bought the beautiful device below, a Breville hot cup, on her recommendation, because I keep dumping the contents of just-boiled kettles all over myself. Means I can have a cup of cherry tea even when I'm not being supervised by the mrs. Yum =)

The picture shows a black and blue kettle-type object,
that dispenses water into a cup placed under a spout,
rather than needing to be poured.

You'll get better, won't you?

Every so often, I find myself tied up in knots by a conversation that goes along these lines :

What's wrong with your knees / feet / hips / legs ?
I have a joint problem / connective tissue disorder / my joints are too bendy / mind your own business
Oh, are they sore?
Yes
You will get better won't you? / How long until you can stop using the stick? / You're too young to have joint problems
[Mumble something incoherent]

I know they "mean well" but can't people engage their brain before they open their mouthes. What am I supposed to say? No sorry, I won't get better, I'll probably just get slowly worse. Or, I'm sorry, I didn't realise 23 was too young, I'll stow my stick away for 60 years shall I?. Or, I'm sorry that my condition upsets you.

What do they expect me to say? How can it "not be fair"? It's my life, who "deserves" it more or less than me?

My friends get to say these things to me, my family. I'm not selfish enough to think that I'm the only person who has to deal with this, and I'm not arrogant enough to tell them how to deal with it. It's a really big deal.

But strangers or vague acquaintances - people on the bus, patients, folk at church, bored med students - please, think. When you think this stuff out loud I am obliged to make it seem alright. To say Oh, it's not so bad, you get used to it, actually the stick really helps. You oblige me to make it something simple, manageable, put-in-a-box-able.

And it's hard to do that, because it's my life. This isn't just about using a stick, it's about a condition that has changed my whole life. It's not all negative, not all the changes are bad - but it has changed my whole life.

It's not like you're stuck for options. Maybe try that must be hard / oh, I hadn't realised / your stick is AWESOME (because it is), or even just OK.

Just, y'know, I've had to reassure 4 complete strangers today. About my health. And that's really tiring.

Gatekeepers

I am not, by nature, an assertive person. I am getting better at it, but I'm still not great. As you may have gathered, I'm one of these folks who nods meekly on the outside, while seething on the inside and then rants to my other half about all the things I wish I'd said.

This is especially problematic when dealing with doctors. All doctors, especially GPs have essentially two functions :
1) To diagnose / manage conditions and do other doctor-ly things
2) To act as "gatekeepers" to other services

I used to expect my GP to telepathically know that "my joints still hurt" means "please refer me to rheumatology", because I was too afraid of seeming demanding by asking for what I wanted. I'm finding it a bit easier these days, especially since I was introduced to the Assertive Method (really well worth a read, I like to glance over it before each time I go to the GP). For example :

• Step 1 - I have been telling you about my joint pain for 2 years now, and it's been getting worse, not better.
• Step 2 - I am feeling overwhelmed by these symptoms at the moment, and I don't know how to cope.
• Step 3 - I would like you to refer me to rheumatology so that I can get a proper diagnosis, and some more help.
• Step 4 - What do you think?
• GP - I don't think that's necessary, there's no sign of inflammatory arthritis, your RF and ANA are negative, hypermobility can cause a bit of joint pain etc, etc, etc.
• Step 3 - I would like a referral anyway, so that I can get a proper diagnosis, and some more help.
• GP- OK.
  

The picture shows a green metal gate with flowers
worked into it. It is dark, and through the gaps you
can see a passing car, and a red traffic light.

It might not always work, but it is very effective. And, more importantly sometimes, if it doesn't work, you still have your dignity. When your relationship with a doctor is battered and bruised because they constantly seem to disbelieve you, your dignity is important.

I've been on the other side of this tactic - for example a student-led consultation with a gentleman who was completely insistent about getting some diazepam. He would not be talked down, over and over again "I just want my tablets". In the end my GP tutor gave him the prescription.

There is a reason doctors aren't allowed to prescribe for themselves or their nearest and dearest. Sometimes you need a bit of outside impartiality in your life. But, it's important to be educated about your health, and your condition - and sometimes that will mean that you literally do know better than your GP.

How do you guys, especially medics / expert patients, deal with your GPs in their gatekeeping role?

Applying for DSA

I don't currently claim DSA (or DLA for that matter) and I never have, although I would have been eligible for each of the last 5 years at uni. In the first couple of years I wasn't aware of it (the disability service as my uni is useless, more on that later), then I didn't believe that my mental health problems were significant enough for me to need help (I did).

In terms of current issues, the disability service wouldn't see me until after I had a diagnosis, which meant a big delay, and then I find out that they "don't deal" with benefits. The union offers can "help me fill in the forms", but I don't really rate them, especially compared to some of the websites there are around.

I was diagnosed in January, and I haven't had a break since. I have other things to spend my time on rather than filling in miles of form, and I am very lucky in that my parents are able to support me for the time being. My plan is to apply for DSA over the summer, and to leave DLA until after my finals next year. I want to wait and see what the DLA situation is by then before putting myself through the hassle.

I'm waiting until the summer because due to some quirk of the NHS, I've had a fees bursary this year so needed to apply through them, but next year I thought I'd be back to my LEA, and it all seemed a bit confusing. Not it seems I'm actually having a fees bursary next year as well, in which case it's the NHS all along. Never simple...

I am lusting after these gloves - they're like wetsuit material,

and supposed to be much better for bendy hands than
horrible rigid splint supports with velcro-y nonsense all over

I have been told that applying for DSA is actually a relatively pleasant process. I wish I had applied before, but I am trying to focus on the future these days. I'm told that my diagnosis letter is all I'll really need, plus filling in the forms, and then I'll have an assessment.

Having said that, it all got off to a bit of a bad start. (I wish this was a joke but it's not) I emailled the NHS bursary folk saying "I wondered if I could get some information about applying for DSA", and got a reply saying "please return the attached form together with a psychologist's report". I spent half an hour wondering how intense the process must be if they need a psychologist to assess your mental wellbeing first. Until I figured out that the NHS seem to assume that any disabled medical student is dyslexic. I sent a rather snooty email back asking if a rheumatologist letter would do instead, as psychologists don't tend to deal with joint problems.

Even though there's only a year left, there are some things that would be really help.

Have any of you applied for DSA? Did you have a useful experience?

Elective (nearly)

It's going to be an interesting few weeks I think. I'm heading to the country of my woman and her kin to spend a month in paediatrics in July. Hooray!

The pros :
1) Kids are awesome
2) Change of scene after 6 months straight placement here
3) If I help feed the babies, I get to cuddle the babies
4) I mentioned that I was disabled when trying to negotiate hours, and the administrator replied offering to sort me out a permit for disabled parking as the staff car park is up steps, without being asked! Miraculous!
5) I get to meet more of my lovely partner's lovely friends
6) Extra paeds practice before finals, and the chance to fit in some ob/gyn maybe, which I haven't covered yet
7) Daft cat gets to come too
8) I get to blow bubbles on placement without getting funny looks (purely for the kids' entertainment you understand)

The cons :
1) [redacted by my future self]
2) We will be travelling heavy, as daft cat can't just be tucked in a bag or something ;)
3) We end here on Friday afternoon, and start there (~8 hours journey away) on Monday morning
4) Little patients puke up on you more than growed up patients
5) The mrs gets her extroverted nature from her folks, and they always seem to worry that little introverted me is sad, when I'm just being

The pros have it I guess! I'm curious to see how a different (but still NHS) trust / hospital handles disabled staff. I imagine it'll be pretty much the same - good/bad/buttugly.

It's all going to be alright

After a glum few days (as evidenced by the cheery nature of previous posts), I woke up this morning feeling a bit more rested. I made some yumtastic porridge for me and the girl to celebrate.

Every few months I have a meeting with a doctor who is the pastoral support person for the med school. I go in full of thing to ask / cry / complain about, and I come out 20 minutes later knowing that it's all going to be alright. I remain in a zen state for anywhere between an hour and a month, because Dr A* has a gift.

She listens. How simple does that sound? But I mean really, actively, openly listens. I have never felt judged in that room, I have never felt doubted, I have never felt lazy, or incompetent or weak, or any of the other things that doctors regularly make me feel. I have only ever felt valued, and cared for. It is a space that I can celebrate successes without worrying that they make me seem less unwell. I think I cry and laugh in equal measure. She knows my fiancee's name, knows that I'm vegan, knows where I go to church, knows that I love to cook and sing and travel.

Today we were talking about me working less than fulltime. She accepted my decision, knowing that I would have thought it through. I told her that I was most worried about being resented by my colleagues and feeling like I wasn't properly part of the time, and she said "You know, and I know, that you aren't choosing an easy option. Your training will probably be as hard for you as it is for your fulltime colleagues, and it will be protracted." It made me feel better. I hate people thinking that I'm lazy, it's something that I really don't deal with very well.

The gift of being listened to, even when there's very little pratical she can do for me within the structure of the course, is unbelievable. I'm pretty sure that without Dr A I would have left the course a long time ago, when I was struggling with my mental health.

I hope that I can learn from her how to listen, to my patients, and to my family and friends. To truly listen, not to try and jump in with easy solutions, or to shy away from hearing difficult things because there's nothing I can do to change them. If I can one day do for someone what Dr A has done for me, I will be a happy woman.

*as she shall be known (yes, A stands for awesome...)

Ten years time

Today the (future) missis and I were chatting about the future. We know where we want to be in 10 years. She wants to be a GP, with a special interest in the clap clinic, I want to be working a couple of days a week in something medical or paediatrics. We want to be living in the area that we live in now, and working in this bruised and beautiful city where we first met. We will be married, and on the path to adoption. We will be doctors, but not only doctors - we will be mothers, friends, spouses, daughters, sisters, Guide leaders and home-makers. When we get married, we will know what it means to love each other when we're sick and when we're well.

We know what we want our lives to look like, but there's just that little bit of extra uncertainty for us. I need to work less than full-time, and we need to live together because she is my carer. Foundation years are complicated for anyone, but there's just that little bit of extra hassle for us. We will have to be more organised, more disciplined and more patient. We will have less money. Where other people are stretched, we will be stretched just that little bit further.

Add up a lifetime of 'just-a-little-bit-harder's, and eventually you reach the straw that breaks the camel's back. We have given up a lot for medicine, but we will not give up everything. We are living day-to-day to make it through these few months, these few years until we graduate, because you can't study medicine part time. We are living day-to-day on the understanding that one day it will be different. On the understanding that one day those things that make life worth living will not be sucked into the vacuum that medicine creates in my energy.

When is enough, enough?

Going through the motions

I love medicine. The intricacies of each system of the body, the complexity of patients as people and not diseases, the little surge of smile I get when I make a correct diagnosis, or when I find a vein that no one else did ...I even have a favourite bacteria (it's really very clever).

I am good at what I do. I am not the best, I don't get straight As, I can't name all the bones in the hand or remember more than 3 causes of finger clubbing at any one time, I'm not ground-breaking, I'm nothing special, noone's going to name something after me any time soon, but I am good at what I do. I can get a 4 year old to giggle the whole way through an examination, and muster a good enough my-mum-was-a-ward-sister voice to hush the mouthiest of drunks. I have laughed and cried and sung with patients, I have chased a naked patient making a break for freedom, I have watched patients die. I have made tea, and changed nappies, and taken blood. I am often the first face people will see on a new ward.

I love what I do, and I care about my patients. It has cost the NHS hundreds of thousands of pounds to train me to be a doctor, but there is no guarantee that when I graduate I will be able to work. This might sound like an over-dramatic statement, but it is in fact quite realistic. I am certain that I will not manage to complete the foundation programme on a fulltime basis. It is technically possible to complete it on a less-than-fulltime basis, but it means more hoops to jump through (providing evidence etc), and it is on a pro rata basis (as in, I would still need to be fit to do nights and on calls, which remains to be seen).

Medicine is seeming less and less of a viable career path for me. Even if I become a doctor, my career will not be the career that I had expected. This has been a gradual realisation for me over this last year, and I don't think it's really sunk in. Every time I find myself having a conversation about what the future might look like I get really upset. I feel like I have no other marketable skills - or at least no other marketable qualifications - and that anything else will always feel like second best.

I feel like I've withdrawn a bit from medicine - I'm not excited about placements these days, or wanting to go and spend time on the wards. I feel like I'm just doing what I have to and no more, which isn't like me. It's like I can't bear to get excited about it anymore, because it might not be.

It would be worse if I felt myself physically incapable of practising medicine, but I don't. I'm just not able to work within the training programme as it is - but semantics make no difference. Either way I am shut out of my profession.

I feel numb.

Double Standard

You can tell a lot about a consultant using one simple test : when they ask you a question, and you get the answer right, what do they do? The nice ones smile and move on to the next mumbling wreck student. The ones with a god complex keep asking questions until you get one wrong.

If they see you the next day, they're the ones who'll ask you the same question. And you'd better get it right.

My GP has known about my official diagnosis since January (and I first told him what I thought it was - correctly - last summer). He has still (evidently) failed to read anything about it. I just don't understand that mindset. I understand being busy, but to my mind being properly educated about how to manage your patients is not an optional part of the job. If he was supervising me and I suggested a management plan for a patient with a condition I'd never heard of, he'd tell me to go away and read up.

I wouldn't even mind, at this point, if he just said 'you've obviously been reading up about it, tell me what you know'. If he just showed an interest in actually managing things.

Still.

He's better than the locum covering for him last week who told me that I would get better by taking ibuprofen, having physio and losing weight.

She nearly stopped my tramadol, which whilst not being hugely effective, is certainly better than paracetamol alone (does she not think I tried that first? no?). She suggested I only take it when the pain is bad (someone's forgotten her basics of pain management). Oh, and then implied that I was lying about the fact that ibuprofen makes me wheezy. I'm not sure what I would gain from that, but whatever floats your conspiracy theory.

She was confident in her proposed 'cure', despite having never heard of my condition, and being unable to even pronounce it.

And then she told me I was depressed. I'm not.

People keep implying or outright saying that my pain is my former mental health problems in a new guise. So much so that the rheumatologist I saw diagnosed with me with depression. I'm not depressed.

The most frustrating thing is that 1) If people think I have a psychological problem, surely they should refer me back to psych services 2) When I was depressed, it took me months to persuade anyone to do anything. Months. They were so desperate not to 'put labels' on anything that I ended up in a complete mess.

I'm sick of the double standards. I'm sick of learning the art of medicine, but being treated by doctors who don't listen, don't care and don't know anything about my condition. I'm sick of not being well enough to work for the NHS because NHS doctors can't get their act together to manage my illness. I'm sick of the bloody NHS, sick of being a medic, sick of being a patient, sick of being too tired to be anything other than a medic and a patient. I'm sick of being treated like a giant pain in the arse, all the time.

Intertwined...

I can't get enough of the NHS.

I've been a patient in 11 hospitals (that I can remember), with an appointment for my 12th next week. This is what a sickly and depressed youth will do for a person. I've also been registered at 4 GP surgeries.

Since I started following the medical path, I've been on placement in 10 hospitals and 7 GP surgeries. I may have just about maxed out the local ones, but there's an 11th hospital around the corner for my elective, and 1 that could potentially be thrown into the mix next year.

Some days one fix just isn't enough. I go from placement to GP appointment and back again, I spend a morning reading practice CXRs with my girlfriend while I'm waiting for my cardiologist to get around to me in clinic, I sneak in an early battering from my physio before a 9 o'clock ward round. My nightmare favourite is when my rheumy is there handing out timetables at the start of a block.

Yeah, I totally can't get enough of the NHS.

But right now I could really use a holiday. Even if as a mere student I couldn't possibly know what tiredness really feels like*. It's been 5 months since we had a holiday longer than a bank holiday weekend, and there's 2 months left to go. That's hard enough for the non-bendy folk.

Considering that all NHS employees have or will at some point be NHS patients, you'd think they'd spend some time trying to persuade us into healthy working practices. Oh no wait... That's a degree in public health and Bambi-esque naivete** talking.


*Spoken by an FY1 coming off 10 days on call. 'I wish' seemed too churlish a response, so I gave her chocolate instead.

** If you don't get this reference, you are in serious need of West Wing. Now.

Bitterness is not my most attractive quality...

On days like today it takes a good 99% of my combined strength, self-control, fears of repercussion and compassion not to beat certain patients with my stick (with disability comes handy weaponry).

Most patients I see are having a really crappy time - and if they weren't before spending 3h59 on an A/E trolley being target practice for hapless med students, they certainly are after. They are frightened, confused and in pain (and if they weren't before...) and most do their best to get away asap help you find out what's wrong with them. [No, no medical problems. Diabetic, hypertensive, COPD-ish, triple bypass recipient - oh, yes, I was forgetting]

I enjoy placements. I enjoy them because of friendly colleagues, conspiratorial old ladies, dazed men who sing to me, and 30 somethings who share the skittles their kids brought them with said hapless med student.

But on days like today, it takes everything in me not to tell the guy with "11 out of 10" abdo pain that radiates everywhere, and comes with the most impressive voluntary guarding I've ever seen - who has just tackled the 8 flights of stairs back to the ward from a cig break with ease - that I am in pain every day, so I'm maybe not the person to try it on with.

I bite my tongue, of course, because just sometimes there's a massive gunky appendix, or a scarred and sorry liver lurking in that guy's abdomen. And if not that, there must be something else going on. Because who but a hapless med student would spend 3 days hanging around surgical receiving without getting paid for the privilege - unless they hurt, or they need a bed, or some company, or a fix.

Even if they can saunter up the 8 flights, while I wait 15 minutes for the 1 lift in 4 that is cooperating today.