Happy birthday?

Hello gang =)

You won't know you should have missed me, because of my cunning use of that thing what lets you make posts happen from the past (from the future?) when you don't know if there will be internet, but you should have! Don't worry, I'm back...

So, how's this for an I-love-my-life story? I had been in the land of my beloved for a little over 24 hours when I had an unholy puke attack. Charming, I know, but I made a promise with myself to be honest in this wee corner of the blogosphere (not that I'm dishonest in another corner of it, you understand). This means, if you're keeping track, I managed one day of elective, before having two days off sick. How's that for making a good impression? Plus I forgot my meds last night and therefore didn't sleep just to maximise my awake with noone to talk to time.

[pause to give some love to daft cat]

The psych post that should have appeared for you today, combined with a conversation I had with a very-mini-patient's mum the other day have got me thinking.

I know that the post is fairly cheery in tone, and there's no reason for it not to be as I coped with the placements in psych pretty well, my experience of mental health services from the other end was almost universally not good (with the exception of one awesome adolescent consultant, and one equally awesome therapist). Not to mention my recent experience of being diagnosed with a condition that noone's heard of, and everyone's a bit scared of because it doesn't get better, and that makes them feel impotent or something.

This is a not particularly articulate way of saying : every time I think about government cuts, every time I feel the impact of them, every time I see patients hit with them, it makes me angry. We didn't need less of this stuff - we needed more.

More support for psychiatric service users/patients (I realise that I always say patient because I prefer it - if you don't, I apologise) in the community, more provision for pain management courses and ongoing physio for those with chronic conditions, more support for mums who've just been told that their baby will never talk to them. If you want us to work, you need to find us a job that we can actually do before telling us that we are fit for work, you need to not cut funding to groups who working to end discrimination in the workplace, you need to make laws that don't grovel and beg, leaving more loopholes than a rollercoaster.

We needed more, we deserved more, we are worth more. And I can't be coherent, because it doesn't make sense to me. I can't be coherent because I am scared for myself, for my friends - old and new, and for that little baby and his mum.

This is a time when services need strengthening, to build up to deal with our ageing population. We can deal with these people in two ways - primary and secondary prevention, which saves lives, quality of life, and money, or not. If you've only 5 years to persuade people to not vote for you again, the cheaper option is to cut early intervention services. Because the cracks won't show for a few years, and the next guys'll be the ones who end up raising taxes to deal with it.

The NHS turned 63 yesterday. I don't think it's overdramatic to wonder if she'll make 70.

We are living in strange and scary times my friends, but there is hope in the fight, I think.

Tea, biscuits and psychiatry

1) For me, the best bit of psychiatry was that ward rounds involved sitting in a room with tea and biscuits while the patient comes to you. (OK, maybe not the best bit, but it makes a nice change!) They can be very long though, because they tend to be once-weekly, and multidisciplinary.

2) Some wards, especially forensic or intensive care psych wards won't let you work in them if you have mobility problems. There are two main reasons for this - not being able to make a quick enough getaway if somethings kicks off, and the potential for a stick or crutches to be used as a weapon.

Noone mentioned this to me before my placement, but I suppose the people to talk to would be whoever decides which student goes to which ward (to ask them to avoid placing you on secure wards), occie health for the hospital, or your supervisor for the placement to ask if they do any work on a secure ward, and what the local policy is on this.

3) It is worth spending some time with CPNs, to get an idea of how community psychiatric services are organised. House visits may not be possible, depending on issues of accessibility, but CPNs will often run clinics at the CMHT base. If nothing else, ask a CPN to describe their job, and ask a few patients what their experiences are with CPNs.

4) This isn't actually psych-specific, but this is just where it came up for me. My partner would have been placed with one of the doctors who I saw when I was under the CMHT if she hadn't happened to be on holiday. It hadn't occured to me before that I could end up placed with one of my doctors. There is not really any facility to deal with this at my med school, because allocation of supervisors is handled at the hospitals rather than centrally.

If you do end up in that situation, I suppose there are two options : either get in touch with the med school / teaching administrators and ask to be transferred to somewhere else, or sit down with the doctor in quesion and talk about any issues that might come up. It might even be helpful for your consultant to see exactly how you're managing on placement.

5) During my A and E placement, I found it really difficult how certain doctors talked about / to patients who had self-harmed or overdosed. I reported one particular incident to a consultant because it was so inappropriate. I understand the frustration that doctors feel when they feel like they're getting taken away from people who didn't "choose" to be there, but this frustration should not be taken out on patients.

People will not think of the possibility that you, or members of your close family/friends may have been affected by similar issues. There is an 'us' and 'them' mentality, which feels very awkward as someone who is both.

6) If you are likely to be at all triggered by anything that comes up during placement, make sure your 'support network' - partner, friends, family, minister, disability advisor, CPN etc - know that you are starting the placement, and that it may be difficult for you. Make suggestions about how they can best help and care for you, if you know.

7) I have done two psych placements now, and both times I have told my supervisor that "I have a history of mental health problems" so that they knew in case I was struggling. If this feels too personal, or for whatever reason, you could say that a close family member / friend has mental health problems instead. This will hopefully stop them saying stupid things in front of you, will give you a chance to raise any suggestions e.g. "can you give me a brief run down of each patient before they come in so I don't get surprised by anything difficult?", and will explain away your freak-ish knowledge of little-used anti-depressants.

8) I don't normally journal regularly, but I wrote in a journal every day during my two psych blocks, so I could explore anything that had triggered me, and any emotions that the placement had brought up. Having said that, neither I nor any of my friends with MH problems have found the psych block particularly bad. I still think it's a good idea to prepare for the worst, just in case. Have a think about what you can do to cope if you have a tough time of it.

9) Prioritise your own health. Don't put yourself in any situations that you know are bound to cause problems, such as patients with a similar condition or history to you, or those who are aggressive and intimidating. Focussing on some of the theory (side effects of psych meds seem to make for popular exam questions) can help to take out some of the 'sting' of it

10) That being said, you will have to face some psychiatry in both final exams, and as a junior doctor (and, obviously, you will always find patients with mental health problems popping up in other specialities), so you need to find a way to, for example, assess a suicidal patient, and do it well and thoroughly, without damaging your own health. There are no easy answers to this, but I suspect that, as with many things, the key may lie in practice.

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.

Children are not mini adults...

...A survival guide for paediatrics.

1) If you look "different" in any way, children will ask questions about it, and parents will (for the most part) get embarrassed. You've probably come up against it at the supermarket already, but if you haven't, have a think about what to say to "why is that lady using a stick / chair? etc". Something simple such as "my legs don't work the same way as yours" works for younger children, and simply "I am disabled" for older.

Decide to what extent you will answer follow-up questions as well. To non-medics I tend to say that "I have a problem with my joints", and this seems to work fine with children. (Medics, I tend to tell what I have, purely because it's not well-known and I want more people to have at least heard of it!)

2) I try to be welcoming to questions and curiosity from kids, because I think that's it's a really good opportunity to de-mystify disability. If kids are staring, or parents get embarrassed, I tend to ask the wee ones what colour my stick is. It seems to open up some good conversations.

3) I did talk to a couple of parents who said it was really good for their disabled child to see a disabled medical student. I didn't know what to say to that, but it made me a bit happy. This isn't really a tip so much as something to bear in mind.

4) Depending on your life experiences, some of the issues that are raised in paediatrics may raise some difficult feelings. Recognising non-accidental injury, for example, will almost certainly be raised.The pictures shows a young girl of about 3, dressed in red, kneeling over
a baby, dressed in white, who is lying on the floor. The girl is playing
with a syringe (no needle though, don't worry!), and mum is watching
over them, her left wrist loosely bandaged by the wee doctor.
Picture by uncoolbob on flickr.

5) The MDT is highly valued within paediatrics, and specialist community nurses are the back bone of chronic disease management in kids. Depending on access issues, home visits may not be possible for you, but nurses often also run clinics from a hospital base, or are part of consultant-led clinics (e.g. diabetes clinic).

6) I found it really frustrating how much better coordinated childrens services are than adult. There's no easy answer to this, but it's not just you. Don't be afraid to voice these frustrations, because most paediatricians share it, because they see the anxiety that surrounds the transition between.

7) If you've not spent much time with babies before, and you're nervous around them, get the nurses to teach you how to change nappies / give bottle feeds. If you muck in, you'll get plenty of experience, and the nurses / auxillaries will love you. (If you like cuddles, barter one nappy change for one bottle feed like me!)

8) Spend time in the play room or with play therapists to hang out with some toddlers. Being able to make a child smile will make clinical exams so much easier - a relaxed child is way easier to examine, and a relaxed parent gives a better history. The easiest way to get a child on side is to say "who is that on your Tshirt? / what is your teddy's name? / what colour are your shoes? is that your favourite colour?". Always ask the child their name and age before (if they can't answer) asking the parent (unless they're very obviously 8 weeks old!).

9) But, if you choose to take this kind of hands on approach, remember : have a change of top around in case you get peed or puked on. (Or know where the scrubs live!)

10) Also, know your limits in terms of lifting babies / children. Don't hurt yourself (by lifting a particularly weighty, but tiny-looking 2y/o like me...) and really try not to drop them!

Ready? Get set... Surgery

I am not one of life's surgeons. It's medicine all the way for me. Having said that, I came out of my surgical placement this year feeling smarter, more confident and able to present patients a lot more succintly. And I really enjoyed myself. If I can do it, anyone can. Here are some hard won lessons that I will definitely be bearing in mind next year.

On the wards
1) Surgical ward rounds are fast-paced, which makes it hard to sit down at each patient. Consider sitting out alternate patients, or bays in the doctors room. Alternatively, do your own WR over a day. See each patient and review their notes at your own pace. This is very good for learning, especially if you don't peek at the diagnosis before seeing them (except if the patient answers your opening "what was it that brought you to the hospital?" with "I had a massive heart attack"...)

In clinic
2) Surgical clnics are as speedy as the WRs, and doctors tend to walk from room to room as the nurses shuffle the patients so there's not much chance for sitting. Again try seeing alternate patients, or taking regular breaks (starting before you get tired, not after). In certain clinics, for example one-stop breast clinic, it's really useful to shadow one patient through the entire process. This is naturally paced by the queues for each procedure!

Don't always feel the need to stay for a whole clinic. Go to the ward, or the library to read up on what you've seen.

Looking the part
3) Wear clothes that are easy to get in and out of, and compression stockings if you are prone to fainting or getting all oedema-y in the feet when you stand. If you need particularly large, or particularly small scrubs, it's worth snaffling a pair from the hospital buying your own pair (you can get fairtrade ones here).

4) Buy your own clogs if you have musculoskeletal issues. I'm coming to my 6th month of achilles tendinitis and plantar fasciitis after wearing a pair that didn't fit out of the spares bin (even though I was sitting down almost the whole time!). In most places closed toe crocs are fine. You can (at least in my trust) also just wear shoe covers over your normal comfy shoes.

Pictured are a pair of wooden clogs, painted bright orange, against a
grey background that looks like concrete. These would not be practical
for theatre but at all! Picture by garyknight on flickr.

5) I didn't take my stick into theatre, but if I had, I would have made a cover from a pair of old-and-falling-apart scrubs bottoms, or something. I plan to ask a friendly scrub nurse for something suitable next time.
[Update : When I took my stick into theatre, I was just asked to clean it with hard surface wipes. Obviously, I couldn't use it while scrubbed in. When I started using the wheelchair, one hospital let me bring my chair through the changing rooms and just leave it to scrub in, but another made me leave it in the changing room. I talked to theatre sister in advance about when I was going to be where and she helped me sort out a stool to sit on.]

In theatre
6) Scrub in at least once, even if you can't assist. It's a good skill to learn, and it's all kinds of fun. Ask a scrub nurse to show you how to do it properly. If you do assist, don't for more than 10 minutes the first time (even if non-disabled and/or not holding on to a fat flap / retractor). It's harder work than it might look.
[Update : You can sit down while scrubbed in. During my gynaecology placement I assisted for full lists while sitting down.]

7) Ask a scrub nurse or technician for a spare stool if you can't find one (or ask the anaethetist to borrow theirs if they're not using it). Theatre stools don't usually have back support, so it might be worth talking to you supervisor / disability advisor to try and sort something out if that's a problem. [Update : one hospital I had placement in also had higher stools (think barstool height) which are normally used for optho surgery - these were great for being able to see the field while seated. It's always best to chat to the surgeon about where is best or you to sit so you won't be in the way]

If you can't stand at all, or for long periods, then laparoscopic or opthalmic procedures are great because you can sit and watch what's going on on the screen. Most urology surgeries and some breast surgery (axillary node clearance) are carried out seated so you can see the field sitting down. [Update : I was primary assistant on full gynae lists while seated, without any issues.]

8) Pace yourself. Seeing 3 of the same procedure back to back is not the best use of your time. Sit often, for short periods - don't wait until breaking point to have a rest, and between patients go and sit in a more supportive chair in the break room, and have a drink and snack.

9) Drink plenty of water, don't skip breakfast, and don't be embarassed to sit down or leave if you feel dizzy. It's much less embarassing that fainting into the surgical field (luckily I didn't learn that one by experience!)

10) If you don't have a specific anaesthetics placement, spend some time with anaesthetists during your surgical placements. They are very good at explaining physiology (but be warned, they also ask really tough questions about it...), and there are plenty of chances for procedures (venflons, airways etc). Plus there's lots of sitting. Next time I also plan to shadow a scrub nurse for a list.

Questions

Over the next few weeks, I'm going to try and find out some answers to the following questions. If you know the answer, or how I might find out, please let me know in the comments. If you'd like to add something else to the list, then leave a comment and I'll do my best.

- What support is available through the BMA for disabled med students
- How to access the BMA chronic illness matching scheme

- What adaptations have been made for people during their final clinical exams, especially those with pain / fatigue issues

- What some other people's experiences are of being a disabled medical student or junior doctor (if you'd like to write a guest post, let me know)
- What some examples of med schools being good at dealing with disabled students are
- What equipment is available for D/deaf and visually impaired/blind medics (I'm curious)

- How less-than-fulltime FY1/FY2 years are structured, other than the basic nights and weekends on a pro rata basis stuff (for example, will I end up doing 4 foundation years? will I have to apply for the last 2 as a locum, or will they be sorted out for me? etc)
- Whether Access to Work or Occupational Health can be any use in providing adaptations for the workplace, considering how short junior posts are

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?