tag:blogger.com,1999:blog-13896010066297576582023-11-16T22:06:24.054+11:00Ars Medicinakkhalilrhttp://www.blogger.com/profile/07210124426451234275noreply@blogger.comBlogger60125tag:blogger.com,1999:blog-1389601006629757658.post-61083034606598605892016-08-20T23:08:00.001+10:002016-08-26T21:20:59.544+10:00HeroesI'm attending the 2016 RACGP 'Women in General Practice' conference in <div>Melbourne this weekend and the excitingly brilliant day of learning has ended with a dinner with one of my heroes.<div><br></div><div>Professor Leanne Rowe is the co-author of 'First Do No Harm: Being a resilient doctor in the 21st century'; the other co-author being Professor Michael Kidd, another hero of mine.</div><div><br></div><div>In the time she was speaking to us, without her realising it, Professor Rowe had answered every single one of the lingering questions that have been painfully plaguing my mind for the past 6 months.</div><div><br></div><div>A part of me felt relieved and ever so grateful. Another part of me felt guilty, embarrassed and ashamed.</div><div><br></div><div>She reminded me of the person I aspired to be. And it wasn't the list of accolades and accomplishments that she's acquired over the years (although they indeed are mind-blowingly impressive)... It was her. Not Leanne Rowe the Professor... But Leanne Rowe the woman, the mother, the general practitioner.</div><div><br></div><div>I have spent a large percentage of my life in pursuit of my life's true purpose, with life events leading me down the path of General Practice. But in light of that, I look at myself and my life right now and I can't help but feel somewhat out of place. I don't recognise my reflection. I feel uncomfortable under my skin. I feel betrayed and like I've been a betrayer.</div><div><br></div><div>I've put my life on hold when I said I wouldn't. I've let go parts of myself when I promised myself I'd hold on to them. I've focused on the wrong things, I've got my priorities mixed up and it feel like the foundations under me have shifted.</div><div><br></div><div>I've let my fears and unrealistic expectations of myself direct me down a road that, while I enjoy taking, would have much rather strolled through while stopping occasionally to sniff the roses and admire the view, rather than whizzing by on the bullet train.</div><div><br></div><div>After deliberating for so long and agonising over what would be the right way to live out the next 5 to 15 years of my life, I have finally found the courage to make the decision to live my life the way I want to, and not the way I feel that I should.</div><div><br></div><div>I'm putting on the brakes and stepping off the bullet train. I think it's time I put my runners on and went for a stroll instead. Recharge myself to the fullest and take in some solitude.</div><div><br></div><div>To Professor Leanne Rowe... Although I doubt you will likely ever stumble upon this... In the off-chance that you do...</div><div><br></div><div>I just wanted to say, Thank you. </div></div>kkhalilrhttp://www.blogger.com/profile/07210124426451234275noreply@blogger.com0tag:blogger.com,1999:blog-1389601006629757658.post-38321993319662152942016-03-06T07:59:00.001+11:002016-03-06T07:59:26.231+11:00A Brave New WorldThere is a certain discomfort that comes with doing something new and unfamiliar. Quite often though, it's the initial bit that scares you, but once you've actually done it, the anxiety dissipates and you come out of it with the knowledge that you've conquered something.<div><br></div><div>As a brand new General Practice Registrar, every day and every patient is new and unfamiliar. There is so much to learn and just when you think you've got it down, you get thrown a curve ball.</div><div><br></div><div>If I could give some advice to my past-self from a month ago, it would be this.</div><div><br></div><div>Get used to the feeling of discomfort. You and it are going to be best friends for a while.</div><div><br></div><div>There will be wins and you'll get some time to recover if you make time and effort for it, but ultimately, it's going to be hit after hit after hit, and you won't get a choice but to get up each and every time.</div><div><br></div><div>Set up a good support system. You'll need it like a drowning person needs a lifeline.</div><div><br></div><div>And above all else, don't lose sight of why you're in it. It's the only thing that's going to get you through.</div>kkhalilrhttp://www.blogger.com/profile/07210124426451234275noreply@blogger.com0tag:blogger.com,1999:blog-1389601006629757658.post-45542306034444695632015-05-09T21:58:00.001+10:002016-03-06T07:30:54.817+11:00The Come-Back<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);"><i>Nothing so frightens me as writing, but nothing so satisfies me.</i></span><div><span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);"><b><br></b></span></div><div><span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);"><b>Maya Angelou</b></span></div><div><span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);"><br></span></div><div><span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);"><br></span></div><div><span style="-webkit-text-size-adjust: auto;">I am a writer. I always have been.</span></div><div><br></div><div><span style="-webkit-text-size-adjust: auto;">When I think of the things that define me, what comes to mind is not my profession, but what has led me to it.</span></div><div><span style="-webkit-text-size-adjust: auto;"><br></span></div><div><span style="-webkit-text-size-adjust: auto;">My first love was a love for the written word. As a child, I loved nothing more than to curl up with a good book, churning through multiple in a day. My day would begin and end with the usual things that filled the life of a child, but I still strongly recall the joy that I found in those quiet moments when it was just me and those incredible words that illustrated different lives and far-away worlds that seemed foreign and yet all too familiar.</span></div><div><span style="-webkit-text-size-adjust: auto;"><br></span></div><div><span style="-webkit-text-size-adjust: auto;">I started my first journal at the age of 7, and wrote my first serious novel not too long after that. From there, I went on to writing poetry and, after teaching myself the guitar and drums, moved on to writing songs. My love for music, art and literature preceded my love for medicine. I was an artist long before I ever imagined becoming a doctor.</span></div><div><br></div><div><span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);">Author Joan Walsh Anglund once wrote, "A bird doesn't sing because it has an answer, it sings because it has a song." Writing, like all my artistic pursuits, has always been about self-expression. I write for me; to organise my thoughts, to make sense of my world. I write what I know, and although what I know is extremely limited, writing helps me put it together and figure it all out.</span></div><div><span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);"><br></span></div><div><span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);">Since I stepped into the world of medicine, it feels like every other part of me has needed to come second to my pursuit of being the best doctor I can be. My writing, my art, my music... Language and philosophy... Health and fitness... Family and friends... Everything else has been allocated a smaller piece of the pie because medicine just takes up so much.</span></div><div><span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);"><br></span></div><div><span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);">I have recently been given the opportunity to write an article on a topic that means a lot to me. It scares me that I might not do it justice because I'm so out of practice, but it's a piece that I would love to write well.</span></div><div><span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);"><br></span></div><div><span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);">I </span><span style="font-family: 'Helvetica Neue Light', HelveticaNeue-Light, helvetica, arial, sans-serif; -webkit-text-size-adjust: auto;">can only hope that, in my attempt, I'll find what I need to make it great. </span><span style="font-family: 'Helvetica Neue Light', HelveticaNeue-Light, helvetica, arial, sans-serif; -webkit-text-size-adjust: auto;">And here's hoping that I find a bit more of myself in it as well.</span></div><div><span style="font-family: 'Helvetica Neue Light', HelveticaNeue-Light, helvetica, arial, sans-serif; -webkit-text-size-adjust: auto;"><br></span></div><div><span style="font-family: 'Helvetica Neue Light', HelveticaNeue-Light, helvetica, arial, sans-serif; -webkit-text-size-adjust: auto;">Wish me luck.</span></div>kkhalilrhttp://www.blogger.com/profile/07210124426451234275noreply@blogger.com0tag:blogger.com,1999:blog-1389601006629757658.post-30272585542155314622015-01-26T22:26:00.001+11:002015-01-31T13:40:22.087+11:00ResidentIn the last month, I've understood the full extent of the term 'hospital resident'.<div><br></div><div>Yeah, ladies and gentleman, that's me.</div><div><br></div><div>I spent most of my year as an ED resident, which hasn't been too bad to me in terms of working hours, as you're typically rostered for 76 hours a fortnight. Given the high intensity of the work, this is understandable... You wouldn't be able to function very well in a cardiac arrest if you've worked 140 hours a fortnight as you sometimes do as a specialty resident. <span style="font-family: 'Helvetica Neue Light', HelveticaNeue-Light, helvetica, arial, sans-serif;">Sleep deprivation results in your brain cells committing suicide and the last place you'd want to be working in with that kind of mental reserve is the Emergency Department.</span></div><div><br></div><div>ED has been fun. I've even taken up the Emergency Medicine Certificate this year because I've enjoyed it so much, and I wanted to get something out of it. Probably the only thing I would change about my year in ED is that the year has been mostly unsupervised, given that night shifts are only covered by 2 residents. There are no consultants on overnight and there are no ED registrars ever.</div><div><br></div><div>As an ED resident, I've had the opportunity to cover specialty wards after hours and overnight, which adds a bit of variety to the work. But again, you're pretty much the senior on-site. Don't get me wrong, I've loved the experience and I've gained plenty of new skills... I just feel like on the flip side, I've missed out on opportunities to learn from a mentor, which is really what being a junior medical officer is all about. To me, the lack of supervision is a pretty big deal... Especially at this stage of my career. Sure, I'm qualified to do the job... That doesn't mean that I wouldn't love the opportunity to learn from someone who's done the job for far longer than I have.</div><div><br></div><div>My last month at the hospital involves me working as both the Hospital Redesign HMO (a position I've held for most of 2014) while working full time as the Paediatric Resident. As expected, Paediatrics has been fun. There's been a lot of learning and mentoring opportunities, as the treating team consists of just me and the 4 rotating Paediatricians. As we do not have Paediatric Registrars, I'm pretty much performing that role... Except I'm paid as a junior medical officer. There have been plenty of opportunities for procedures and I've even gone to doing the last few unsupervised as my skill and confidence have grown.</div><div><br></div><div>As much as I love the work, the days are long and fairly busy. It takes a lot out of you. I've been rostered for seven 14-hour days a fortnight, which include cover shifts where I'm also responsible for the O&G and Psychiatry wards as well, including admissions and discharges. I was on the phone with one of the Paediatric Infectious Disease Consultant in a metropolitan hospital a couple of weeks ago and at the end of the discussion she asked, "I've spoken to you quite a few times this week... What are you still doing in the hospital at this hour of day on a weekend?" After I explained what my rostered fortnight to her looked like, she exclaimed in disgust, "That is just ghastly!"</div><div><br></div><div>Indeed, it is... But, hey... Somebody has to do it.</div><div><br></div><div>It certainly didn't help that all the other residents decided to take their annual leave all at the same time, followed by a couple of them being off sick. When it came down to it, there were so few of us left that we needed to take on extra shifts but even then, everyone agreed that I have the worst roster by far. I really does feel like I'm residing in the hospital. The good of it is that it's great for experiential learning, the bad of it is that I'm exhausted... And that's not very conducive to learning.</div><div><br></div><div>However, I'm on the home stretch. I've done the hard yards and I'm almost at the finish line. After today, it's just one more day and I'll be done. So that's what I keep telling myself.</div><div><br></div><div>Just one more day... And then I'll get my rest.</div>kkhalilrhttp://www.blogger.com/profile/07210124426451234275noreply@blogger.com0tag:blogger.com,1999:blog-1389601006629757658.post-72488582872337333242014-07-23T22:01:00.001+10:002014-07-23T22:01:35.959+10:00Sick DaysThis is getting ridiculous.<div><br></div><div>No sooner have I recovered from the URTI from hell (that's 'Upper Respiratory Tract Infection' for all you non-medicos), here comes the gastroenteritis.</div><div><br></div><div>The plague never ends.</div><div><br></div><div>The good news is that I'm currently rostered on 4 days off after a 6-day stretch.</div><div><br></div><div>The bad news is that I'm meant to be attending classes for these next 4 days, before going back to work on a 10-day stretch.</div><div><br></div><div>The bottom line is... I'm far too busy to be unwell!!! 😫</div><div><br></div><div>But it is how it is. Willing myself not to fall sick does not unfortunately make it so.</div><div><br></div><div>Despite all my efforts with hand hygiene, protective gloves and face masks, the bugs still get me. Partly due to my crappy immune system, partly due to the sheer volume of exposure.</div><div><br></div><div>And, yet... I doubt it's just me, but it's incredibly hard to take sick days when you're a doctor. Even when you're entitled to it; even when you need it; even when it's the right thing to do. It's really hard.</div><div><br></div><div>For starters, sick or not, if you don't show up to work, there's no one to do your job. Guess what happens then? Your colleagues are asked to not only manage their unmanageable workload, but also yours as well.</div><div><br></div><div>Another side of it is, nobody really cares about doctors being unwell. Especially other doctors. They just want you to be at work because hey, they're also sick and they're at work! Why shouldn't you be?</div><div><br></div><div>In any other profession, you'd call that sadistic. In medicine though, it's just the culture.</div><div><br></div><div>Puking your guts out? Take a chill pill and some metoclopramide. Bloody diarrhoea? Here's a cup of concrete, you'll be alright. (Disclaimer: That was sarcasm, not a prescription...)</div><div><br></div><div>We all know the rules with gastro. If a hospital worker gets gastro, they're meant to stay home until 48-hours post the last episode to minimise the risk of transmission to others (colleagues and patients alike).</div><div><br></div><div>Realistically though, I know a doctor who once had an acute gastro attack on his shift and rightfully informed the senior doctor of this. The senior doctor then said, 'No big deal. Just push on, it's all good.'</div><div><br></div><div>You might be thinking, 'I'm sorry, but I don't think it's right for doctors to be treating patient when they're sick, particularly not when they're infectious.'</div><div><br></div><div>My response to that is, 'Congratulations! Right answer. And while I whole heartedly agree with you, medicine can be a really cruel and thoughtless profession sometimes.'</div><div><br></div><div>I find this particularly true when it concerns the intraprofessional expectations of fellow doctors.</div><div><br></div><div>A nurse once said to me, 'Medicine is the only profession I know of where they eat their young.'</div><div><br></div><div>Young or old, I think doctors do tend to have very little compassion for other doctors. And that's a terrible shame.</div><div><br></div><div>According to Beyond Blue's 2013 'National Mental Health Survey of Doctors and Medical Students', 40% of medical professionals perceived their fellow doctors to be less competent if they have had a history of mental illness and 59% felt that being a patient results in embarrassment for the doctor. Sad to say, stigma within the medical profession is alive and well.</div><div><br></div><div>If you've ever wondered why there are so many doctors out there who seem tactless and uncaring and appear to lack compassion, it's because to a certain extent, the profession breeds them. The perception is that it's the 'tough' doctors that survive the decades of rigorous training, ragging and gruelling hours. The profession prides itself on being resilient; on rising above the decades of physical, mental and emotional torture and abuse that is perceived to only make us stronger.</div><div><br></div><div>And often it does. But amidst all the success stories, you can't look away from the other side of the truth.</div><div><br></div><div>We don't all escape the trauma of self-neglect unscathed.</div>kkhalilrhttp://www.blogger.com/profile/07210124426451234275noreply@blogger.com0tag:blogger.com,1999:blog-1389601006629757658.post-74686685865022605732014-02-06T10:36:00.001+11:002014-02-06T11:12:29.172+11:00Mirrors and WallsI was on Day 3 as a resident.<div><br></div><div>I was in a new department, working with new people, fulfilling a new role in a new rotation.</div><div><br></div><div>Even on Day 3, I still felt completely lost.</div><div><br></div><div>She was on Day 3 at her new job.</div><div><br></div><div>She was in a new town, working with new people, fulfilling a new role in a new and unfamiliar field.</div><div><br></div><div>And on Day 3, she was stretched to her limits.</div><div><br></div><div>We spoke about the stressors of her new work and life, the guilt that comes with putting herself above a commitment that she's made, and the feelings of uncertainty and inadequacy that she felt in her new role. We talked about the difficulties she was facing and discussed options that could assist with making things better.</div><div><br></div><div>Even today, I'm not sure if the nature of the discussion we had was part of my role as an ED resident, but I stuck with it because it was what needed to be discussed. If not now, then when, and if not me, then who?</div><div><br></div><div>As I worked within the limits of our professional relationship to defuse some of her fears and anxiety, I had to make a conscious effort to go against some of my own natural responses that were driven by my instincts of compassion and empathy and this was a real challenge.</div><div><br></div><div>Medicine is a paradox of incredible proportions. Isn't it funny how the exact qualities that draw individuals into the profession, the very fundamental values that we seek to instill in our doctors and the ones that we identify present in good doctors, are the ones that they are often required to silence in order to appropriately fulfil their roles?</div><div><br></div><div>I have no doubt that she will be okay. All that she really needs is time to prove to herself that she, in the words of Christopher Robin, is "braver than she believes, stronger than she thinks, smarter than she thinks", and that there are always options in her favour. And in the time that she is discovering that, all she needs is someone to be kind to her on days when she hasn't got the ability to be kind to herself.</div><div><br></div><div>In retrospect, I wonder if some would have thought that I had spent to much time with her in that consult. The truth was that I took as much time as I needed to get the work done. </div><div><br></div><div>I gave her the time she deserved, the time that she needed and the time that I secretly wished I could give to myself for the same purpose.</div><div><br></div><div>In the end though, I think what matters most is that we ended the consultation with her stating, "I don't feel sick anymore".</div><div><br></div><div>Amidst all my doubt about whether I'm following all the rules, fulfilling all the criteria and being and doing my best, I can't help but be extremely comforted by her parting statement.</div><div><br></div><div>After all, if my patients can honestly say that they feel better after a consult, surely I must be doing something right.</div><div><br></div><div>Isn't that what I'm ultimately here for?</div>kkhalilrhttp://www.blogger.com/profile/07210124426451234275noreply@blogger.com0tag:blogger.com,1999:blog-1389601006629757658.post-87733464561109213192013-08-23T15:16:00.001+10:002016-08-26T21:26:41.811+10:00What Kills You... And What Makes You Stronger.It is my first fortnight on General Medicine and it has been brutal.<div><br></div><div>Not only has there been the compulsory Week 1 breakdown, there has been around 6 breakdowns in the past 12 days.</div><div><br></div><div>While covering the wards last weekend, I felt completely burnt out. But of course, Monday came along so I kept on going.</div><div><br></div><div>That's just what you do.</div><div><br></div><div>I started out the year on my 20-week GP rotation, and I loved every minute of it. Moving on to Orthopaedics was tough, but as the trend seems to go, you find that you start to get the hang of things by Week 9, only to switch rotations after Week 10 and end up back where you started - lost in unfamiliar surroundings.</div><div><br></div><div>All throughout my internship year thus far, there have been ups and downs, but ultimately I have found that I've been enjoying my training tremendously and even at the worse of times, I love what I do.</div><div><br></div><div>General Medicine, however, has been hard. It's a hard unlike anything else I have ever known.</div><div><br></div><div>It's the kind of hard that makes you run like your life depended on it, then knocks the wind out of you and then as you crash to the ground, delivers a fatal blow to the back of your skull.</div><div><br></div><div>You don't want to get back up, but you do anyway.</div><div><br></div><div>What makes you do this?</div><div><br></div><div>The fact that you don't have a choice.</div><div><br></div><div>It's do or die.</div><div><br></div><div>I started my rotation thinking of what a great opportunity this would be to learn and grow in my clinical skills and experience. But now I just feel bruised and battered. I'm just tired.</div><div><br></div><div>The real danger is that exhaustion has a tendency of beating the enthusiasm out of you. In the past fortnight I've tried so hard to struggle through the exhaustion and to fight off the apathy. It has not been easy, and it required me to call upon an internal strength that I did not know I had.</div><div><br></div><div>Now that I'm finally facing my first day off since starting on Gen Med, I still find my thoughts stuck on the wards. It's a form of psychological trauma.</div><div><br></div><div>Have I done all the blood slips for the weekend? Are there investigations that I haven't followed up? Have I missed something important?</div><div><br></div><div>That's the problem with hospital medicine. The work never ends and as everyone else has their own work to do, there's no one to cover you if for whatever reason you don't do yours.</div><div><br></div><div>And at the end of the day, after being so invested in the treatment and progress of so many patients, it's hard to just shut off when you finally get to leave the wards.</div><div><br></div><div>Another problem with hospital medicine is the high turnover rates and the high patient load. As an intern, your days are busy and there are always investigation results to chase up, referrals to be made, tests to order, notes and drug charts to write up, admissions to be done.</div><div><br></div><div>The work is constant, and a reliable pen is your best friend. With my 30 - 40 patients a day load in the past fortnight, I have very easily run dry a total of 4 pens.</div><div><br></div><div>With the nature of the job being so task-oriented, it's very easy to lose sight of why you're there. It's also easy to lose the empathy - there are just too many pressures on you at any one time, and when you're struggling to catch your own breath, it's very easy to inadvertently look over someone else who is also struggling to breathe.</div><div><br></div><div>Rather unfortunately, their lives depend on you. So sink or swim, your patients are your priority.</div><div><br></div><div>Rightly or wrongly, medicine involves a lot of self-sacrifice. It involves sacrificing your time, your life, yourself, for someone else, simply by virtue of the role that you choose to take on by being a doctor.</div><div><br></div><div>We are told on airplanes that when cabin pressures are low, you first need to put the oxygen mask on yourself before attending to those under your care.</div><div><br></div><div>It's an important principle, but unfortunately the medical world has not yet adopted this principle. It is expected that doctors take care of themselves, but the nature of the work and the hours that we work do not logistically allow us to do this.</div><div><br></div><div>It is undeniable though that when exposed to a consistent state of low oxygen, the body learns to adapt. We learn to function at a much higher level than most under much less desirable circumstances. We become stronger.</div><div><br></div><div>Still, there is a fine line between learning to thrive under extreme circumstances and failing to thrive. Everybody has a limit and often the factors that test those limits are not within our control.</div><div><br></div><div>Sometimes it feels like a game of chance. Like Russian-Roulette.</div><div><br></div><div>If you're pushed hard enough... Who is going to be the next to have a breakdown?... Who is going to be the next to make a mistake?...</div><div><br></div><div>Who is going to be the next one to stop caring?...</div><div><br></div><div>Because when the work ceases to be fun... When it starts feeling like a chore and all you do is rush about doing your daily jobs to get them all done before midnight, which is 2 hours past the time you were meant to leave, knowing full well that you have to be back at work at 6am...</div><div><br></div><div>When you're pushed so hard that your own reserve tanks of hope, love and joy run empty and you couldn't care less about anyone else's wellbeing...</div><div><br></div><div>That's when it ceases to be good medicine.</div>kkhalilrhttp://www.blogger.com/profile/07210124426451234275noreply@blogger.com0tag:blogger.com,1999:blog-1389601006629757658.post-82599919284358104962013-07-08T00:29:00.000+10:002013-07-08T00:29:02.777+10:00WorkI've often marvelled at how amazing it is to be granted the privilege to do the work that I do.<br />
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It truly is a privilege to be able to wake up every morning, go to work and care for the sick.<br />
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To be able to gain insight into their lives, to help make them better, to be trusted with their stories and their secrets, to have their families trust you to care for the ones they hold most dear; it is an extraordinarily humbling profession.<br />
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Today came with a lot of 'firsts' for me:<br />
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<ol>
<li>I managed my first acutely unwell patient from start to finish</li>
<li>I took my first set of ABGs</li>
<li>I experienced my first "breaking of bad news"</li>
<li>I certified my first death</li>
</ol>
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It's been a long 16-hour day, and I start up again in 6 hours, so I should probably get some sleep.</div>
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The thing is... Given the day I've had, it's not exactly easy to come home at the end of the day and wind down. The adrenaline, which is so crucial to keeping you going while you're at work, doesn't just switch off when you leave the hospital. It takes time to wear off.</div>
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But now that the silence has overcome me, I'm ready to call it a night.</div>
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And at the end of the day, this is what I think about being a doctor:</div>
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The job is hard, but the work is good.</div>
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When you put everything you have into it, you start to get into the flow of things and it just feels right. And when everyone works together and does their part well, it feels like a symphony.</div>
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You cannot do medicine by halves, and I cannot think of anything else I'd rather be doing.</div>
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I love my job.</div>
kkhalilrhttp://www.blogger.com/profile/07210124426451234275noreply@blogger.com0tag:blogger.com,1999:blog-1389601006629757658.post-41308280462099965682013-06-10T23:10:00.001+10:002013-06-15T13:42:45.487+10:00Hotel CaliforniaMedical Internship is a little like going to war.<div><br></div><div>A lot happens, some of it traumatising, and at the end of the day, you don't really want to talk about it.</div><div><br></div><div>Since I've decided to chronicle my internship year however, it would be remiss of me to back out of it now.</div><div><br></div><div>So let's get ourselves up to speed.</div><div><br></div><div>At present:</div><div>- I have just completed my second week of Orthopaedic Surgery, in which I have worked between 11 and 16 hours without breaks</div><div>- I have been working for 12 days straight, 3 of which have been a long weekend cover shift, in which I covered the Orthopaedic ward, along with General Surgery, ENT, Urology and Rehab</div><div><br></div><div>The work is good and I really enjoy it. However, my work is all I have been doing for the past 12 days.</div><div><br></div><div>In the past fortnight, I have felt unrested, uncleansed, and unfed. If you walked into my apartment you'll find a pile of dirty dishes in the sink, a pile of dirty laundry on the floor, a rubbish bin full to the brim, and piles and piles of things around the place which have yet to be unpacked from when I "moved in" two Sundays ago.</div><div><br></div><div>I leave for work before the sun rises and I return from work after the sun has long set. This is not an unusual pattern of schedule for a medical professional, but it does not mean that it is right.</div><div><br></div><div>All it means is that all I want to do when I get home from work is sleep. All other aspects of my life outside of work - family, friends, recreational activities... All things that make me sane - are all placed on the back burner; as if you're familiar with Maslow's hierarchy of needs, you'll know that physiological needs tend to raise above those of safety, love, esteem and belonging.</div><div><br></div><div>Regardless, I've had a good first fortnight. I love my patients, my colleagues are a pleasure to work with, and the administration provide me with a lot of support and encouragement. All these factors make me feel like I'm working for a purpose - a worthwhile cause - and that I'm a part of something much bigger that I, and that is good quality healthcare.</div><div><br></div><div>The only problem with me working 12 days in a row, other than exhaustion, life neglect and sleep deprivation, is the fact that it is so hard to leave when you eventually do get some time off.</div><div><br></div><div>I am in Melbourne this weekend to attend my interview and entrance exam to get into the General Practice Training Programme and while I'm aware that my thoughts and attention should be here with me, I can't help but wonder about my patients in hospital and how they are doing.</div><div><br></div><div>I wonder if the interventions I performed yesterday helped at all. I wonder if any of my patients are getting discharged over the weekend. I wonder if anything eventful occurred overnight (and I hope the answer to this is, No).</div><div><br></div><div>It makes me feel like the hospital is a little bit like Hotel California.</div><div><br></div><div>You can check out any time you'd like (assuming it's rostered), but you can never leave.</div>kkhalilrhttp://www.blogger.com/profile/07210124426451234275noreply@blogger.com0tag:blogger.com,1999:blog-1389601006629757658.post-55516409351762182032013-05-07T21:05:00.001+10:002013-05-12T20:33:56.797+10:00The Sick DoctorOne of the hardest things for a doctor to do is to be a patient.<br>
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There are many factors that contribute to doctors not being able to take on the sick role, and it's often not as straight forward as simply not wanting to.<br>
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For starters, all doctors know that there is a gradient to being sick, and theoretically, there is a point in that gradient line in which you are deemed "too sick to go to work".<br>
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However, in practice, it's actually very, very difficult to properly ascertain where you are on that list. It is hard to be objective when it concerns your own health, which is why it is always valuable for a doctor to have their own personal doctor; an independent assessor capable of making the call that you should be off-duty.<div><br></div><div>Why is it important to have someone to take that decision away from you?</div><div><br></div><div>It can be very easy for a doctor to say "It's just a cold, I'll soldier on" because a lot of the time, it takes a lot more effort to take a sick day than it is to just go to work even though you shouldn't. For a specialist, it means rescheduling appointments that have been booked months in advance; for interns, residents, and registrars, it means finding someone else to do the work you were assigned to do.</div><div><br></div><div>Whether in hospital or in clinic, when you're a doctor, there's always more work to be done than there are hours in a day. And more often than not, you're the only one who can do your job because other doctors have way too much on their plate already. Quite simply, there is no one to pick up your slack.</div><div><br></div><div>It is undeniable, however, that a sick doctor is no good to anyone. Not only do you risk spreading illness to your patients and colleagues (further contributing to countless hours of loss productivity), your physical, mental and emotional states are compromised and you're more likely to make mistakes.</div><div><br></div><div>And in medicine, mistakes are costly and not tolerated very well.</div><div>
<br>All the same, there seems to exist an expectation within the medical profession, conscious or subconscious, for doctors to push through adversities. Whether it's related to physical, mental, or emotional drain; whether it's due to excessive working hours, unpaid overtime, lack of personal or professional support, work or life stressors or illness of any sort, we all seem to be expected to suck it up and be okay anyway.<br>
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Despite being constantly reminded throughout medical school about the importance of taking care of ones health, the comment one of my supervisors made regarding my need to get some time off to visit the doctor was, "Do that while you can, because when you get to my level, there's no such thing as taking time off. When I get sick, I still have to go to work."<br>
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And therein lies the hypocrisy of medicine. What they tell you to do and what they really expect you to do are often two completely different things. <br>
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One of my colleagues recently confessed to me that she has been struggling with the hours and jobs required of her in her medical rotation. In fact, she was having such a hard time at work that she felt she needed to bring the matter up with the Director of Medical Services so they could together find a solution that could improve her situation.<br>
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The response she was met with was appalling. The DCT essentially said, "Suck it up, this is medicine, when I was at your level I had it 100 times worse. I'd be lucky to have a rotation like yours."<div><br></div><div>My thoughts? Tyrant.</div><div><br></div><div>And this is not an uncommon scenario.</div><div><br></div><div>My personal thoughts are, it doesn't matter that back in "the good old days" doctors were expected to slave over inhumane hours which were both hazardous to their health and their patients' health. There's a reason why we have put a stop to the Dark Ages. It wasn't working for us. Just because you had it hard, doesn't mean that it's okay; and it definitely doesn't mean that you need to condemn others to the same fate. </div><div><br></div><div>In that regard, I have a lot of respect for the nursing profession. Nurses adhere religiously to their stop and start times, they take multiple schedules breaks a day, and are extremely ferocious about guarding these sacred rights. And, more importantly, they look out for each other. They ensure that their fellow nurses take breaks and leave when they're supposed to.</div><div><br></div><div>The habit is so inspiring that I can't help but wish that they were just as watchful over their doctor colleagues!</div><div><br></div><div>Unlike a lot of my colleagues, I've been very lucky in my rotation so far and I've had wonderful, amazing nurses working with me who care about my health and wellbeing. In fact, it was under the advice of a senior nurse that I took my sick leave and I'm very grateful to her for pushing for it. I had really needed it, but the weight of my supervisor's expectations (and my own) was urging me to push on.</div><div>
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</div></div><div>At the end of the day, we are a team. And like any team, we are only as weak as our weakest link. I think it's important for us to look out for one another and stand up for one another when the occasion calls for it.</div><div><br></div><div>We all acknowledge that no one is superhuman. We are not immune to disease and when we come across someone who needs a hand with taking on the sick role when they rightfully deserve it, I'd like to think that we could defend that persons right, just like we would want someone to defend our own rights to it when the time comes.</div><div><br></div><div>It is incredibly sad to note that, from my observations thus far, compassion is a virtue that is incredibly scarce in the medical profession, despite the fact that it requires it most.</div><div><br></div><div>It is both frustrating and disappointing, and I can only hope that this improves in my future observations but until then, I suppose the most I can do is to follow Ghandi's advice and be the change I wish to see in the world.</div>kkhalilrhttp://www.blogger.com/profile/07210124426451234275noreply@blogger.com0tag:blogger.com,1999:blog-1389601006629757658.post-54653856766059997442013-03-28T12:01:00.001+11:002013-03-28T12:01:13.020+11:00GP-LandThis week has been particularly stressful.<br />
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But I'm sure I say that every week.<br />
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Amidst having plenty of complicated cases present at the clinic, I also had to suture a laceration yesterday that was approximately 10cm in length, and fairly gaping.<br />
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It was good practice, I was thankful for the opportunity to further my experience, and I feel I did a good job. Still, my neck and back ached by the end of it, and as soon I was done, I had to rush to the hospital to give a presentation about Wide Complex Tachycardia to an audience of consultants, registrars, interns, medical students, and nurses. Oh, and also the President of the Royal Australasian College of Physicians.<br />
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No pressure.<br />
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Thankfully, with a lot of preparation and a touch of good luck, the presentation went well and I felt really positive about it. I was a massive wreck in the couple of months preparing for it though! It's nice to be able to look at it retrospectively and say that it was a success.<br />
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I'm currently on my 11th week of General Practice and around week 9, I finally felt like I was getting the hang of things. Given that all the rotations in our internship year (other than GP, if you're in my internship programme) is 10 weeks in duration, it's a little unfortunate that you only feel like you've finally got the job down just before they ship you off to another one.<br />
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But that's the nature of internship training, I guess. They like to keep us on our toes.<br />
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I like General Practice. That was one of the main reasons I selected my internship programme. I figured that after 20 weeks of GP, surely I'd have a better idea about whether or not I'd pursue it as a career.<br />
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What I've found, however, is that although I still find GP-Land a nice place to be I'm, I've developed a thirst for other specialties, particularly Emergency and Paediatrics.<br />
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I have an ED rotation at the end of the year, and I'm very much looking forward to that. I'd like to look into getting some experience in Paediatrics next year as well. And, of course, I still could be a General Practitioner and sub-specialise in Emergency and Paediatrics.<br />
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Decisions, decisions...<br />
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The good news is, I'm in no rush to decide.kkhalilrhttp://www.blogger.com/profile/07210124426451234275noreply@blogger.com0tag:blogger.com,1999:blog-1389601006629757658.post-31071492441959265092013-03-22T01:30:00.001+11:002013-03-22T01:30:35.469+11:00SleepI have just come home from the hospital after attending to patients who were affected by a tornado that's hit not too far from here, and all I want to do... Is read.<br />
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I know I should be sleeping.<br />
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I still need to go to work tomorrow morning, as I have patients booked in to see me. I still might get called back in tonight if we received any more admissions. And I've been in theatre all day after having very little sleep the night before due to a case of food poisoning.<br />
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So, yes... I'm well aware that I should be sleeping. But I'm wide awake.<br />
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I'm finding myself flipping through my medical textbooks, looking for more information. My mind feels thirsty for knowledge... I feel like I need to fill it, refresh it, with questions to ask, symptoms and signs to look out for, medications and dosages... All for the next patient that comes through those hospital doors.<br />
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I want to be good at this. I don't want to miss anything.<br />
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Which is why... Despite not wanting to... I'm going to power off my brain and get some sleep.<br />
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It's counter-intuitive to me at the moment, but I know it's the right things to do.<br />
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I need it.kkhalilrhttp://www.blogger.com/profile/07210124426451234275noreply@blogger.com0tag:blogger.com,1999:blog-1389601006629757658.post-56823247156834005192013-02-05T23:32:00.001+11:002013-02-12T23:16:56.224+11:00Heal ThyselfIt is a fact universally acknowledged that in comparison to a large proportion of the general population, doctors are paid relatively well.<br />
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If the perspective of someone working in this field is anything to go by, there are some days when you realise that you are not paid nearly enough for the work that you are expected to do.<br />
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Being a doctor is hard.<br />
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And being a good doctor? That's even harder.<br />
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The job is time intensive, labour intensive, stress filled, all consuming, unhealthy and often thankless.<br />
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People have asked me, what's it like being a new doctor?<br />
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I smile and say, it's fantastic, and on most days, this is true.<br />
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But then there are days when what I really want to say is this:<br />
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It's like going to work in the morning, finding out that one of your patients has unexpectedly died overnight and wondering... What exactly happened? How could this have happened? Was it something I've done? Was it something I didn't do? How do I fix this?<br />
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But you can't.<br />
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It's like finishing a 36-hour shift (or an 8-hour shift or a 14-hour shift), making your way back home and not being able to shake the feeling that you've forgotten something... And you hope and you pray that whatever you've missed wasn't something big. And you lay at bed at night thinking... Have I done something today that might have adverse effects on someone's quality of life? Have I done something wrong that can't be fixed?<br />
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But your head is cloudy from fatigue and the day is all a blur and you remember next to nothing, as hard as you might try.<br />
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And after a while, you are overwhelmed by the futility in wondering and you pass out from exhaustion.<br />
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Or... You stay awake in bed. Which is worse.<br />
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You stay awake in bed, fully aware that in a short couple of hours, you will be expected to be on the wards once again. And the longer it takes to get to sleep, the less sleep you will get, the more of a zombie you will be in the morning and the more mistakes you will make.<br />
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If you're lucky, the anxiety and adrenaline eventually wears off and you find yourself asleep. Until, that is... You find yourself waking up in the middle of the night, every hour, wondering... Is it time for work yet? Should I be getting up now? Am I late for work? Where's that ward list that I needed to update?<br />
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What is it like being a new doctor?<br />
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It's like feeling exhausted after a long shift and wanting nothing more than to drive home and get into bed but knowing that driving after being awake for as long as you have is extremely unsafe. In fact, it's like you've got a blood alcohol that's above the legal limit.<br />
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So here's the question... If you're not allowed to drive in that state, how on Earth would it ever make sense that you'd be allowed to prescribe lethal drugs or make life and death decisions? How could you ever be expected to be sharp enough not to miss anything?<br />
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But you are.<br />
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As a doctor, you're expected to function at 100%, 100% of the time.<br />
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Your days consist of answering questions. Questions from patients, families, senior staff, junior staff, students, other members of the healthcare team... All of which you will be expected to know how to answer. You are expected to know everything about everything at all times.<br />
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As a doctor, your job is to care for other people, regardless of how you're feeling. If you show up to work and you're sick/tired/depressed/run down, well, suck it up, princess. There's only room for one sick person in a consulting room, and you're not it.<br />
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There are days when you think, I would give an arm and a leg for just one more hour of sleep, and those are the days when the money isn't worth it.<br />
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You lay in bed, unable to move, and you think, can't I just pay them to let me stay in bed? If I have a mental break down, will they finally leave me alone?<br />
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At that stage, the prospects of becoming criminally insane (or trading your stethoscope for a desk job, depending on your temperament) are excruciatingly tempting, believe me.<br />
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And then... There are the cover shifts. An untamed monster of stress and anxiety of demonic proportions. On-call days are mildly better in terms of stress levels, but only mildly.<br />
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In GP-Land, your days are filled with patients, one after another, and there's not much time in between to think. Just like working in ED, everyone that comes through your door is there for a different reason and although there's no way to anticipate what that reason might be, you've got to be prepared for it all regardless.<br />
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If you've forgotten something, or if something has slipped your mind during a consultation, you'll be lucky if you ever remember it because as soon as one patient leaves, another one comes in. And always, the most important patient is the one sitting in front of you. It's them who is entitled to your full attention, not the one that you've just seen, and you need to get it right every time.<br />
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If, like me, you're lucky enough to get awesome supervisors who love to teach and are good at doing it, there's also an element of stress that comes into play where you don't want to disappoint them. You want to do your best, be the best, and always be one step ahead of the learning experience. And often that internal pressure and stress is just as bad as the external ones that you have to deal with.<br />
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Being a doctor is hard.<br />
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So why so we do it?<br />
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Different doctors do it for different reasons. For me, and for most of my doctor friends (or colleagues, as those grown-ups say), we do it because there is nothing else that we'd rather do when we wake up in the morning (and sometimes late in the night) than exercise the privilege of helping our patients.<br />
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I suspect that the 'I want to help people' line is getting a little old these days at medical school interviews and thus probably isn't very likely to secure you an admission. However, I've found in my recent experience that, as cliched as it may seem, it's only cliched because nothing explains it better.<br />
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I watch myself and my friends go through so much hardship for this job, it's incredible. Day and night, week after week, we put aside our wants and our needs, push through our comfort zones, time and time again, for the sole reason that it is expected of us. The world expects it of us, and we expect it of ourselves. We do not question it, we do not settle for mediocrity.<br />
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Except for the occasional lazy intern, and believe me, there are unfortunately plenty of those going around making a nuisance of themselves. The rest of us though, are fairly hard workers.<br />
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And what makes it good, is when we get to the bedside of Mrs Jones or Mr Smith and we get to tell them in all honesty that we are doing the best we can to make things better for them. There is no joy in the world that's quite like the one you get when you gain someone's trust, and feeling like you want to do right by them. It is seriously empowering, and it gets you through all the rough days, every time.<br />
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And that is why I do it. That's my reason for waking up in the morning.<br />
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The way I see it, nobody likes being sick. But if my patients have to be sick, the least I could do is make the experience a little better for them, not just through medical intervention, but also through my interaction with them.<br />
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After all, in my short years through life and medicine, I've learnt that a little smile, a little laughter, and a little bit of humanity goes a very, very long way.<br />
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And, without a doubt, it is not only healing for the patient - it heals the physician as well.<br />
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We simply would not survive without it.kkhalilrhttp://www.blogger.com/profile/07210124426451234275noreply@blogger.com2tag:blogger.com,1999:blog-1389601006629757658.post-72142732069478178852013-01-20T14:00:00.001+11:002013-01-20T14:04:06.214+11:00The Secret of...<div align="center" class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 10pt; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; mso-outline-level: 2; text-align: center;">
<b><span style="color: black; font-size: 18pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';"><span style="font-family: Calibri;">The Care of the Patient<o:p></o:p></span></span></b></div>
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<span style="font-family: Calibri;"><i><span style="color: black; font-size: 12pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';">Francis W. Peabody, MD<br />Boston</span></i><span style="color: black; font-size: 12pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';"><o:p></o:p></span></span></div>
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<span style="font-family: Calibri;"><span style="color: black; font-size: 18pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';">I</span><span style="color: black; font-size: 12pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';">t is probably fortunate that systems of education are constantly under the fire of general criticism, for if education were left solely in the hands of teachers the chances are good that it would soon deteriorate. Medical education, however, is less likely to suffer from such stagnation, for whenever the lay public stops criticizing the type of modern doctor, the medical profession itself may be counted on to stir up the stagnant pool and cleanse it of its sedimentary deposit. The most common criticism made at present by older practitioners is that young graduates have been taught a great deal about the mechanism of disease, but very little about the practice of medicine—or, to put it more bluntly, they are too "scientific" and do not know how to take care of patients. <o:p></o:p></span></span></div>
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<span style="color: black; font-size: 12pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';"><span style="font-family: Calibri;">One is, of course, somewhat tempted to question how completely fitted for his life work the practitioner of the older generation was when he first entered on it, and how much the haze of time has led him to confuse what he learned in the school of medicine with what he acquired in the harder school of experience. But the indictment is a serious one and it is concurred in by numerous recent graduates, who find that in the actual practice of medicine they encounter many situations which they had not been led to anticipate and which they are not prepared to meet effectively. Where there is so much smoke, there is undoubtedly a good deal of fire, and the problem for teachers and for students is to consider what they can do to extinguish whatever is left of this smoldering distrust. <o:p></o:p></span></span></div>
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<span style="color: black; font-size: 12pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';"><span style="font-family: Calibri;">To begin with, the fact must be accepted that one cannot expect to become a skillful practitioner of medicine in the four or five years allotted to the medical curriculum. Medicine is not a trade to be learned but a profession to be entered. It is an ever widening field that requires continued study and prolonged experience in close contact with the sick. All that the medical school can hope to do is to supply the foundations on which to build. When one considers the amazing progress of science in its relation to medicine during the last thirty years, and the enormous mass of scientific material which must be made available to the modern physician, it is not surprising that the schools have tended to concern themselves more and more with this phase of the educational problem. And while they have been absorbed in the difficult task of digesting and correlating new knowledge, it has been easy to overlook the fact that the application of the principles of science to the diagnosis and treatment of disease is only one limited aspect of medical practice. The practice of medicine in its broadest sense includes the whole relationship of the physician with his patient. It is an art, based to an increasing extent on the medical sciences, but comprising much that still remains outside the realm of any science. The art of medicine and the science of medicine are not antagonistic but supplementary to each other. There is no more contradiction between the science of medicine and the art of medicine than between the science of aeronautics and the art of flying. Good practice presupposes an understanding of the sciences which contribute to the structure of modern medicine, but it is obvious that sound professional training should include a much broader equipment. <o:p></o:p></span></span></div>
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<span style="color: black; font-size: 12pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';"><span style="font-family: Calibri;">The problem that I wish to consider, therefore, is whether this larger view of the profession cannot be approached even under the conditions imposed by the present curriculum of the medical school. Can the practitioner's art be grafted on the main trunk of the fundamental sciences in such a way that there shall arise a symmetrical growth, like an expanding tree, the leaves of which may be for the "healing of the nations"? <o:p></o:p></span></span></div>
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<span style="color: black; font-size: 12pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';"><span style="font-family: Calibri;">One who speaks of the care of patients is naturally thinking about circumstances as they exist in the practice of medicine; but the teacher who is attempting to train medical students is immediately confronted by the fact that, even if he could, he cannot make the conditions under which he has to teach clinical medicine exactly similar to those of actual practice. <o:p></o:p></span></span></div>
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<span style="color: black; font-size: 12pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';"><span style="font-family: Calibri;">The primary difficulty is that instruction has to be carried out largely in the wards and dispensaries of hospitals rather than in the patient's home and the physician's office. Now the essence of the practice of medicine is that it is an intensely personal matter, and one of the chief differences between private practice and hospital practice is that the latter always tends to become impersonal. At first sight this may not appear to be a very vital point, but it is, as a matter of fact, the crux of the whole situation. The treatment of a disease may be entirely impersonal; the care of a patient must be completely personal. The significance of the intimate personal relationship between physician and patient cannot be too strongly emphasized, for in an extraordinarily large number of cases both diagnosis and treatment are directly dependent on it, and the failure of the young physician to establish this relationship accounts for much of his ineffectiveness in the care of patients. <o:p></o:p></span></span></div>
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<span style="color: black; font-size: 12pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';"><br /></span><b><span style="color: black; font-size: 13.5pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';"><span style="font-family: Calibri;">INSTRUCTION IN TREATMENT OF DISEASE</span></span></b></div>
<span style="font-family: Calibri;"><b><span style="color: black; font-size: 13.5pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';">H</span></b><span style="color: black; font-size: 12pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';">ospitals, like other institutions founded with the highest human ideals, are apt to deteriorate into dehumanized machines, and even the physician who has the patient's welfare most at heart finds that pressure of work forces him to give most of his attention to the critically sick and to those whose diseases are a menace to the public health. In such cases he must first treat the specific disease, and there then remains little time in which to cultivate more than a superficial personal contact with the patients. Moreover, the circumstances under which the physician sees the patient are not wholly favorable to the establishment of the intimate personal relationship that exists in private practice, for one of the outstanding features of hospitalization is that it completely removes the patient from his accustomed environment. This may, of course, be entirely desirable, and one of the main reasons for sending a person into the hospital is to get him away from home surroundings, which, be he rich or poor, are often unfavorable to recovery; but at the same time it is equally important for the physician to know the exact character of those surroundings. <o:p></o:p></span></span><br />
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<span style="color: black; font-size: 12pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';"><span style="font-family: Calibri;">Everybody, sick or well, is affected in one way or another, consciously or subconsciously, by the material and spiritual forces that bear on his life, and especially to the sick such forces may act as powerful stimulants or depressants. When the general practitioner goes into the home of a patient, he may know the whole background of the family life from past experience; but even when he comes as a stranger he has every opportunity to find out what manner of man his patient is, and what kind of circumstances make his life. He gets a hint of financial anxiety or of domestic incompatibility; he may find himself confronted by a querulous, exacting, self-centered patient, or by a gentle invalid overawed by a dominating family; and as he appreciates how these circumstances are reacting on the patient he dispenses sympathy, encouragement or discipline. <o:p></o:p></span></span></div>
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<span style="color: black; font-size: 12pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';"><span style="font-family: Calibri;">What is spoken of as a "clinical picture" is not just a photograph of a man sick in bed; it is an impressionistic painting of the patient surrounded by his home, his work, his relations, his friends, his joys, sorrows, hopes and fears. Now, all of this background of sickness which bears so strongly on the symptomatology is liable to be lost sight of in the hospital: I say "liable to" because it is not by any means always lost sight of, and because I believe that by making a constant and conscious effort one can almost always bring it out into its proper perspective. The difficulty is that in the hospital one gets into the habit of using the oil immersion lens instead of the low power, and focuses too intently on the center of the field. <o:p></o:p></span></span></div>
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<span style="color: black; font-size: 12pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';"><span style="font-family: Calibri;">When a patient enters a hospital, one of the first things that commonly happens to him is that he loses his personal identity. He is generally referred to, not as Henry Jones, but as "that case of mitral stenosis in the second bed on the left." There are plenty of reasons why this is so, and the point is, in itself, relatively unimportant; but the trouble is that it leads, more or less directly, to the patient being treated as a case of mitral stenosis, and not as a sick man. The disease is treated, but Henry Jones, lying awake nights while he worries about his wife and children, represents a problem that is much more complex than the pathologic physiology of mitral stenosis, and he is apt to improve very slowly unless a discerning intern happens to discover why it is that even large doses of digitalis fail to slow his heart rate. Henry happens to have heart disease, but he is not disturbed so much by dyspnea as he is by anxiety for the future, and a talk with an understanding physician who tries to make the situation clear to him, and then gets the social service worker to find a suitable occupation, does more to straighten him out than a book full of drugs and diets. <o:p></o:p></span></span></div>
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<span style="color: black; font-size: 12pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';"><span style="font-family: Calibri;">Henry has an excellent example of a certain type of heart disease, and he is glad that all the staff find him interesting, for it makes him feel that they will do the best they can to cure him; but just because he is an interesting case he does not cease to be a human being with very human hopes and fears. Sickness produces an abnormally sensitive emotional state in almost every one, and in many cases the emotional state repercusses, as it were, on the organic disease. The pneumonia would probably run its course in a week, regardless of treatment, but the experienced physician knows that by quieting the cough, getting the patient to sleep, and giving a bit of encouragement, he can save his patient's strength and lift him through many distressing hours. The institutional eye tends to become focused on the lung, and it forgets that the lung is only one member of the body. <o:p></o:p></span></span></div>
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<b style="mso-bidi-font-weight: normal;"><span style="color: black; font-size: 12pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';"><br /></span></b><span style="font-family: Calibri;"><b><span style="color: black; font-size: 13.5pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';">PATIENTS WHO HAVE "NOTHING THE MATTER WITH </span></b><b style="mso-bidi-font-weight: normal;"><span style="color: black; font-size: 13.5pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';">THEM"</span></b></span><span style="color: black; font-size: 12pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';"><br /></span><span style="font-family: Calibri;"><b><span style="color: black; font-size: 13.5pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';">B</span></b><span style="color: black; font-size: 12pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';">ut if teachers and students are liable to take a limited point of view even toward interesting cases of organic disease, they fall into much more serious error in their attitude toward a large group of patients who do not show objective, organic pathologic conditions, and who are generally spoken of as having "nothing the matter with them." Up to a certain point, as long as they are regarded as diagnostic problems, they command attention; but as soon as a physician has assured himself that they do not have organic disease, he passes them over lightly. <o:p></o:p></span></span></div>
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<span style="color: black; font-size: 12pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';"><span style="font-family: Calibri;">Take the case of a young woman, for instance, who entered the hospital with a history of nausea and discomfort in the upper part of the abdomen after eating. Mrs. Brown had "suffered many things of many physicians." Each of them gave her a tonic and limited her diet. She stopped eating everything that any of her physicians advised her to omit, and is now living on a little milk and a few crackers; but her symptoms persist. The history suggests a possible gastric ulcer or gallstones, and with a proper desire to study the case thoroughly, she is given a test meal, gastric analysis and duodenal intubation, and roentgen-ray examinations are made of the gastro-intestinal tract and gallbladder. All of these diagnostic methods give negative results, that is, they do not show evidence of any structural change. The case is immediately much less interesting than if it had turned out to be a gastric ulcer with atypical symptoms. The visiting physician walks by and says "Well, there's nothing the matter with her." The clinical clerk says "I did an awful lot of work on that case and it turned out to be nothing at all." The intern, who wants to clear out the ward so as to make room for some interesting cases, says "Mrs. Brown, you can send for your clothes and go home tomorrow. There really is nothing the matter with you, and fortunately you have not got any of the serious troubles we suspected. We have used all the most modern and scientific methods and we find that there is no reason why you should not eat anything you want to. I'll give you a tonic to take when you go home." Same story, same colored medicine! Mrs. Brown goes home, somewhat better for her rest in new surroundings, thinking that nurses are kind and physicians are pleasant, but that they do not seem to know much about the sort of medicine that will touch her trouble. She takes up her life and the symptoms return—and then she tries chiropractic, or perhaps it is Christian Science. <o:p></o:p></span></span></div>
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<span style="color: black; font-size: 12pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';"><span style="font-family: Calibri;">It is rather fashionable to say that the modern physician has become "too scientific." Now, was it too scientific, with all the stomach tubes and blood counts and roentgen-ray examinations? Not at all. Mrs. Brown's symptoms might have been due to a gastric ulcer or to gallstones, and after such a long course it was only proper to use every method that might help to clear the diagnosis. Was it, perhaps, not scientific enough? The popular conception of a scientist as a man who works in a laboratory and who uses instruments of precision is as inaccurate as it is superficial, for a scientist is known, not by his technical processes, but by his intellectual processes; and the essence of the scientific method of thought is that it proceeds in an orderly manner toward the establishment of a truth. Now the chief criticism to be made of the way Mrs. Brown's case was handled is that the staff was contented with a half truth. The investigation of the patient was decidedly unscientific in that it stopped short of even an attempt to determine the real cause of the symptoms. As soon as organic disease could be excluded the whole problem was given up, but the symptoms persisted. Speaking candidly, the case was a medical failure in spite of the fact that the patient went home with the assurance that there was "nothing the matter" with her. <o:p></o:p></span></span></div>
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<span style="color: black; font-size: 12pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';"><span style="font-family: Calibri;">A good many "Mrs. Browns," male and female, come to hospitals, and a great many more go to private physicians. They are all characterized by the presence of symptoms that cannot be accounted for by organic disease, and they are all liable to be told that they have "nothing the matter" with them. Now my own experience as a hospital physician has been rather long and varied, and I have always found that, from my point of view, hospitals are particularly interesting and cheerful places; but I am fairly certain that, except for a few low grade morons and some poor wretches who want to get in out of the cold, there are not many people who become hospital patients unless there is something the matter with them. <o:p></o:p></span></span></div>
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<span style="color: black; font-size: 12pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';"><span style="font-family: Calibri;">And, by the same token, I doubt whether there are many people, except for those stupid creatures who would rather go to the physician than go to the theater, who spend their money on visiting private physicians unless there is something the matter with them. In hospital and in private practice, however, one finds this same type of patient, and many physicians whom I have questioned agree in saying that, excluding cases of acute infection, approximately half of their patients complained of symptoms for which an adequate organic cause could not be discovered. Numerically, then, these patients constitute a large group, and their fees go a long way toward spreading butter on the physician's bread. Medically speaking, they are not serious cases as regards prospective death, but they are often extremely serious as regards prospective life. <o:p></o:p></span></span></div>
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<span style="color: black; font-size: 12pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';"><span style="font-family: Calibri;">Their symptoms will rarely prove fatal, but their lives will be long and miserable, and they may end by nearly exhausting their families and friends. Death is not the worst thing in the world, and to help a man to a happy and useful career may be more of a service than the saving of life. <o:p></o:p></span></span></div>
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<span style="color: black; font-size: 12pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';"><br /></span><b><span style="color: black; font-size: 13.5pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';"><span style="font-family: Calibri;">PHYSIOLOGIC DISTURBANCES FROM EMOTIONAL REACTIONS</span></span></b><span style="color: black; font-size: 12pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';"><br /></span><span style="font-family: Calibri;"><b><span style="color: black; font-size: 13.5pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';">W</span></b><span style="color: black; font-size: 12pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';">hat is the matter with all these patients? Technically, most of them come under the broad heading of the "psychoneuroses"; but for practical purposes many of them may be regarded as patients whose subjective symptoms are due to disturbances of the physiologic activity of one or more organs or systems. These symptoms may depend on an increase or a decrease of a normal function, on an abnormality of function, or merely on the subjects becoming conscious of a wholly normal function that normally goes on unnoticed; and this last conception indicates that there is a close relation between the appearance of the symptoms and the threshold of the patient's nervous reactions. The ultimate causes of these disturbances are to be found, not in any gross structural changes in the organs involved, but rather in nervous influences emanating from the emotional or intellectual life, which, directly or indirectly, affect in one way or another organs that are under either voluntary or involuntary control. <o:p></o:p></span></span></div>
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<span style="color: black; font-size: 12pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';"><span style="font-family: Calibri;">Every one has had experiences that have brought home the way in which emotional reactions affect organic functions. Some have been nauseated while anxiously waiting for an important examination to begin, and a few may even have vomited; others have been seized by an attack of diarrhea under the same circumstances. Some have had polyuria before making a speech, and others have felt thumping extrasystoles or a pounding tachycardia before a football game. Some have noticed rapid shallow breathing when listening to a piece of bad news, and others know the type of occipital headache, with pain down the muscles of the back of the neck that comes from nervous anxiety and fatigue. <o:p></o:p></span></span></div>
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<span style="color: black; font-size: 12pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';"><span style="font-family: Calibri;">These are all simple examples of the way that emotional reactions may upset the normal functioning of an organ. Vomiting and diarrhea are due to abnormalities of the motor function of the gastro-intestinal tract—one to the production of an active reversed peristalsis of the stomach and a relaxation of the cardiac sphincter, the other to hyperperistalsis of the large intestine. The polyuria is caused by vasomotor changes in renal circulation, similar in character to the vasomotor changes that take place in the peripheral vessels in blushing and blanching of the skin, and in addition there are quite possibly associated changes in the rate of blood flow and in blood pressure. Tachycardia and extrasystoles indicate that not only the rate but also the rhythm of the heart is under a nervous control that can be demonstrated in the intact human being as well as in the experimental animal. The ventilatory function of the respiration is extraordinarily subject to nervous influences; so much so, in fact, that the study of the respiration in man is associated with peculiar difficulties. Rate, depth and rhythm of breathing are easily upset by even minor stimuli, and in extreme cases the disturbance in total ventilation is sometimes so great that gaseous exchange becomes affected. Thus, I remember an emotional young woman who developed a respiratory neurosis with deep and rapid breathing, and expired so much carbon dioxide that the symptoms of tetany ensued. The explanation of the occipital headaches and of so many pains in the muscles of the back is not entirely clear, but they appear to be associated with changes in muscular tone or with prolonged states of contraction. There is certainly a very intimate correlation between mental tenseness and muscular tenseness, and whatever methods are used to produce mental relaxation will usually cause muscular relaxation, together with relief of this type of pain. A similar condition is found in the so-called writers' cramp, in which the painful muscles of the hand result, not from manual work, but from mental work. <o:p></o:p></span></span></div>
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<span style="color: black; font-size: 12pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';"><span style="font-family: Calibri;">One might go on much further, but these few illustrations will suffice to recall the infinite number of ways in which physiologic functions may be upset by emotional stimuli, and the manner in which the resulting disturbances of function manifest themselves as symptoms. These symptoms, although obviously not due to anatomic changes, may, nevertheless, be very disturbing and distressing, and there is nothing imaginary about them. Emotional vomiting is just as real as the vomiting due to pyloric obstruction, and so-called "nervous headaches" may be as painful as if they were due to a brain tumor. Moreover, it must be remembered that symptoms based on functional disturbances may be present in a patient who has, at the same time, organic disease, and in such cases the determination of the causes of the different symptoms may be an extremely difficult matter. Every one accepts the relationship between the common functional symptoms and nervous reactions, for convincing evidence is to be found in the fact that under ordinary circumstances the symptoms disappear just as soon as the emotional cause has passed. <o:p></o:p></span></span></div>
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<span style="color: black; font-size: 12pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';"><span style="font-family: Calibri;">But what happens if the cause does not pass away? What if, instead of having to face a single three-hour examination, one has to face a life of being constantly on the rack? The emotional stimulus persists, and continues to produce the disturbances of function. As with all nervous reactions, the longer the process goes on, or the more frequently it goes on, the easier it is for it to go on. The unusual nervous track becomes an established path. After a time, the symptom and the subjective discomfort that it produces come to occupy the center of the picture, and the causative factors recede into a hazy background. The patient no longer thinks "I cannot stand this life," but he says out loud "I cannot stand this nausea and vomiting. I must go to see a stomach specialist." <o:p></o:p></span></span></div>
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<span style="color: black; font-size: 12pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';"><span style="font-family: Calibri;">Quite possibly the comment on this will be that the symptoms of such "neurotic" patients are well known, and they ought to go to a neurologist or a psychiatrist and not to an internist or a general practitioner. In an era of internal medicine, however, which takes pride in the fact that it concerns itself with the functional capacity of organs rather than with mere structural changes and which has developed so many "functional tests" of kidneys, heart, and liver, is it not rather narrow minded to limit one's interest to those disturbances of function which are based on anatomic abnormalities? There are other reasons, too, why most of these "functional" cases belong to the field of general medicine. In the first place, the differential diagnosis between organic disease and functional disturbance is often extremely difficult, and it needs the broad training in the use of general clinical and laboratory methods which forms the equipment of the internist. Diagnosis is the first step in treatment. In the second place, the patients themselves frequently prefer to go to a medical practitioner rather than to a psychiatrist, and in the long run it is probably better for them to get straightened out without having what they often consider the stigma of having been "nervous" cases. A limited number, it is true, are so refractory or so complex that the aid of the psychiatrist must be sought, but the majority can be helped by the internist without highly specialized psychologic technic, if he will appreciate the significance of functional disturbances and interest himself in their treatment. The physician who does take these cases seriously—one might say scientifically—has the great satisfaction of seeing some of his patients get well, not as the result of drugs, or as the result of the disease having run its course, but as the result of his own individual efforts. <o:p></o:p></span></span></div>
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<span style="color: black; font-size: 12pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';"><span style="font-family: Calibri;">Here, then, is a great group of patients in which it is not the disease but the man or the woman who needs to be treated. In general hospital practice physicians are so busy with the critically sick, and in clinical teaching are so concerned with training students in physical diagnosis and attempting to show them all the types of organic disease, that they do not pay as much attention as they should to the functional disorders. Many a student enters practice having hardly heard of them except in his course in psychiatry, and without the faintest conception of how large a part they will play in his future practice. At best, his method of treatment is apt to be a cheerful reassurance combined with a placebo. The successful diagnosis and treatment of these patients, however, depends almost wholly on the establishment of that intimate personal contact between physician and patient which forms the basis of private practice. Without this, it is quite impossible for the physician to get an idea of the problems and troubles that lie behind so many functional disorders. If students are to obtain any insight into this field of medicine, they must also be given opportunities to build up the same type of personal relationship with their patients. <o:p></o:p></span></span></div>
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<span style="color: black; font-size: 12pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';"><br /></span><b><span style="color: black; font-size: 13.5pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';"><span style="font-family: Calibri;">STUDENT'S OPPORTUNITY IN THE HOSPITAL</span></span></b><span style="color: black; font-size: 12pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';"><br /></span><span style="font-family: Calibri;"><b><span style="color: black; font-size: 13.5pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';">I</span></b><span style="color: black; font-size: 12pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';">s there, then, anything inherent in the conditions of clinical teaching in a general hospital that makes this impossible? Can you form a personal relationship in an impersonal institution? Can you accept the fact that your patient is entirely removed from his natural environment and then reconstruct the background of environment from the history, from the family, from a visit to the home or workshop, and from the information obtained by the social service worker? And while you are building up this environmental background, can you enter into the same personal relationship that you ought to have in private practice? If you can do all this, and I know from experience that you can, then the study of medicine in the hospital actually becomes the practice of medicine, and the treatment of disease immediately takes its proper place in the larger problem of the care of the patient. <o:p></o:p></span></span></div>
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<span style="color: black; font-size: 12pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';"><span style="font-family: Calibri;">When a patient goes to a physician he usually has confidence that the physician is the best, or at least the best available person to help him in what is, for the time being, his most important trouble. He relies on him as on a sympathetic adviser and a wise professional counselor. When a patient goes to a hospital he has confidence in the reputation of the institution, but it is hardly necessary to add that he also hopes to come into contact with some individual who personifies the institution and will also take a human interest in him. It is obvious that the first physician to see the patient is in the strategic position—and in hospitals all students can have the satisfaction of being regarded as physicians. <o:p></o:p></span></span></div>
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<span style="color: black; font-size: 12pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';"><span style="font-family: Calibri;">Here, for instance, is a poor fellow who has just been jolted to the hospital in an ambulance. A string of questions about himself and his family have been fired at him, his valuables and even his clothes have been taken away from him, and he is wheeled into the ward on a truck, miserable, scared, defenseless and, in his nakedness, unable to run away. He is lifted into a bed, becomes conscious of the fact that he is the center of interest in the ward, wishes that he had stayed at home among friends, and just as he is beginning to take stock of his surroundings, finds that a thermometer is being stuck under his tongue. It is all strange and new, and he wonders what is going to happen next. The next thing that does happen is that a man in a long white coat sits down by his bedside, and starts to talk to him. Now it happens that according to our system of clinical instruction that man is usually a medical student. Do you see what an opportunity you have? The foundation of your whole relation with that patient is laid in those first few minutes of contact, just as happens in private practice. <o:p></o:p></span></span></div>
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<span style="color: black; font-size: 12pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';"><span style="font-family: Calibri;">Here is a worried, lonely, suffering man, and if you begin by approaching him with sympathy, tact, and consideration, you get his confidence and he becomes your patient. Interns and visiting physicians may come and go, and the hierarchy gives them a precedence; but if you make the most of your opportunities he will regard you as his personal physician, and all the rest as mere consultants. Of course, you must not drop him after you have taken the history and made your physical examination. Once your relationship with him has been established, you must foster it by every means. Watch his condition closely and he will see that you are alert professionally. Take time to have little talks with him—and these talks need not always be about his symptoms. Remember that you want to know him as a man, and this means you must know about his family and friends, his work and his play. What kind of a person is he—cheerful, depressed, introspective, careless, conscientious, mentally keen or dull? Look out for all the little incidental things that you can do for his comfort. These, too, are a part of "the care of the patient." Some of them will fall technically in the field of "nursing" but you will always be profoundly grateful for any nursing technic that you have acquired. It is worth your while to get the nurse to teach you the right way to feed a patient, change the bed, or give a bed pan. Do you know the practical tricks that make a dyspneic patient comfortable? Assume some responsibility for these apparently minor points and you will find that it is when you are doing some such friendly service, rather than when you are a formal questioner, that the patient suddenly starts to unburden himself, and a flood of light is thrown on the situation. <o:p></o:p></span></span></div>
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<span style="color: black; font-size: 12pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';"><span style="font-family: Calibri;">Meantime, of course, you will have been active along strictly medical lines, and by the time your clinical and laboratory examinations are completed you will be surprised at how intimately you know your patient, not only as an interesting case but also as a sick human being. And everything you have picked up about him will be of value in the subsequent handling of the situation. Suppose, for instance, you find conclusive evidence that his symptoms are due to organic disease; say, to a gastric ulcer. As soon as you face the problem of laying out his regimen you find that it is one thing to write an examination paper on the treatment of gastric ulcer and quite another thing to treat John Smith who happens to have a gastric ulcer. You want to begin by giving him rest in bed and a special diet for eight weeks. Rest means both nervous and physical rest. Can he get it best at home or in the hospital? What are the conditions at home? If you keep him in the hospital, it is probably good for him to see certain people, and bad for him to see others. <o:p></o:p></span></span></div>
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<span style="color: black; font-size: 12pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';"><span style="font-family: Calibri;">He has business problems that must be considered. What kind of a compromise can you make on them? How about the financial implications of eight weeks in bed followed by a period of convalescence? Is it, on the whole, wiser to try a strict regimen for a shorter period, and, if he does not improve, take up the question of operation sooner than is in general advisable? These, and many similar problems arise in the course of the treatment of almost every patient, and they have to be looked at, not from the abstract point of view of the treatment of the disease, but from the concrete point of view of the care of the individual. <o:p></o:p></span></span></div>
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<span style="color: black; font-size: 12pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';"><span style="font-family: Calibri;">Suppose, on the other hand, that all your clinical and laboratory examinations turn out entirely negative as far as revealing any evidence of organic disease is concerned. Then you are in the difficult position of not having discovered the explanation of the patient's symptoms. You have merely assured yourself that certain conditions are not present. Of course, the first thing you have to consider is whether these symptoms are the result of organic disease in such an early stage that you cannot definitely recognize it. This problem is often extremely perplexing, requiring great clinical experience for its solution, and often you will be forced to fall back on time in which to watch developments. If, however, you finally exclude recognizable organic disease, and the probability of early or very slight organic disease, it becomes necessary to consider whether the symptomatology may be due to a functional disorder which is caused by nervous or emotional influences. You know a good deal about the personal life of your patient by this time, but perhaps there is nothing that stands out as an obvious etiologic factor, and it becomes necessary to sit down for a long intimate talk with him to discover what has remained hidden. <o:p></o:p></span></span></div>
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<span style="color: black; font-size: 12pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';"><span style="font-family: Calibri;">Sometimes it is well to explain to the patient, by obvious examples, how it is that emotional states may bring about symptoms similar to his own, so that he will understand what you are driving at and will cooperate with you. Often the best way is to go back to the very beginning and try to find out the circumstances of the patient's life at the time the symptoms first began. The association between symptoms and cause may have been simpler and more direct at the onset, at least in the patient's mind, for as time goes on, and the symptoms become more pronounced and distressing, there is a natural tendency for the symptoms to occupy so much of the foreground of the picture that the background is completely obliterated. Sorrow, disappointment, anxiety, self-distrust, thwarted ideals or ambitions in social, business or personal life, and particularly what are called maladaptations to these conditions—these are among the commonest and simplest factors that initiate and perpetuate the functional disturbances. Perhaps you will find that the digestive disturbances began at the time the patient was in serious financial difficulties, and they have recurred whenever he is worried about money matters. Or you may find that ten years ago a physician told the patient he had heart disease, cautioning him "not to worry about it." For ten years the patient has never mentioned the subject, but he has avoided every exertion, and has lived with the idea that sudden death was in store for him. You will find that physicians, by wrong diagnoses and ill considered statements, are responsible for many a wrecked life, and you will discover that it is much easier to make a wrong diagnosis than it is to unmake it. <o:p></o:p></span></span></div>
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<span style="color: black; font-size: 12pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';"><span style="font-family: Calibri;">Or, again, you may find that the pain in this woman's back made its appearance when she first felt her domestic unhappiness, and that this man's headaches have been associated, not with long hours of work, but with a constant depression due to unfulfilled ambitions. The causes are manifold and the manifestations protean. Sometimes the mechanism of cause and effect is obvious; sometimes it becomes apparent only after a very tangled skein has been unraveled. <o:p></o:p></span></span></div>
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<span style="color: black; font-size: 12pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';"><span style="font-family: Calibri;">If the establishment of an intimate personal relationship is necessary in the diagnosis of functional disturbances, it becomes doubly necessary in their treatment. Unless there is complete confidence in the sympathetic understanding of the physician as well as in his professional skill, very little can be accomplished; but granted that you have been able to get close enough to the patient to discover the cause of the trouble, you will find that a general hospital is not at all an impossible place for the treatment of functional disturbances. The hospital has, indeed, the advantage that the entire reputation of the institution, and all that it represents in the way of facilities for diagnosis and treatment, go to enhance the confidence which the patient has in the individual physician who represents it. This gives the very young physician a hold on his patients that he could scarcely hope to have without its support. Another advantage is that hospital patients are removed from their usual environment, for the treatment of functional disturbances is often easier when patients are away from friends, relatives, home, work and, indeed, everything that is associated with their daily life. It is true that in a public ward one cannot obtain complete isolation in the sense that this is a part of the Weir Mitchell treatment, but the main object is accomplished if one has obtained the psychologic effect of isolation which comes with an entirely new and unaccustomed atmosphere. The conditions, therefore, under which you, as students, come into contact with patients with functional disturbances are not wholly unfavorable, and with very little effort they can be made to simulate closely the conditions in private practice. <o:p></o:p></span></span></div>
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<span style="color: black; font-size: 12pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';"><br /></span><b><span style="color: black; font-size: 13.5pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';"><span style="font-family: Calibri;">IMPORTANCE OF PERSONAL RELATIONSHIP</span></span></b></div>
<span style="font-family: Calibri;"><b><span style="color: black; font-size: 13.5pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';">I</span></b><span style="color: black; font-size: 12pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';">t is not my purpose, however, to go into a discussion of the methods of treating functional disturbances, and I have dwelt on the subject only because these cases illustrate so clearly the vital importance of the personal relationship between physician and patient in the practice of medicine. In all your patients whose symptoms are of functional origin, the whole problem of diagnosis and treatment depends on your insight into the patient's character and personal life, and in every case of organic disease there are complex interactions between the pathologic processes and the intellectual processes which you must appreciate and consider if you would be a wise clinician. There are moments, of course, in cases of serious illness when you will think solely of the disease and its treatment; but when the corner is turned and the immediate crisis is passed, you must give your attention to the patient. Disease in man is never exactly the same as disease in an experimental animal, for in man the disease at once affects and is affected by what we call the emotional life. Thus, the physician who attempts to take care of a patient while he neglects this factor is as unscientific as the investigator who neglects to control all the conditions that may affect his experiment. The good physician knows his patients through and through, and his knowledge is bought dearly. Time, sympathy and understanding must be lavishly dispensed, but the reward is to be found in that personal bond which forms the greatest satisfaction of the practice of medicine. One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient. <o:p></o:p></span></span>kkhalilrhttp://www.blogger.com/profile/07210124426451234275noreply@blogger.com0tag:blogger.com,1999:blog-1389601006629757658.post-27042049586527497112013-01-18T21:34:00.001+11:002013-01-19T20:25:12.767+11:00PositiveMy father once told me that when it comes to choosing a profession, choose one that makes you feel excited about getting up in the morning.<br />
<br />
Although I must admit that the past week has been exhausting in all realms of physical, mental, and emotional, and getting up in the morning has very much been an everyday struggle, by the end of each day, I always felt complete. Like I was exactly where I was meant to be, doing what I was always meant to do.<br />
<br />
I had a feedback session with my supervisor yesterday in which she discussed with me some of my strengths that she has observed in the past week. She said I was a good communicator and that I had excellent rapport with my patients. She mentioned that she felt I was a natural teacher and saw in my sessions how much I enjoyed educating my patients. She also said that she liked my sense of initiative and proactive spirit when it came to learning. <br />
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Needless to say, I was very humbled by the session and felt even more inspired to do better and to be better. Although we all try to do the right things, a little validation in the form of positive feedback goes a very long way in terms of reinforcing good habits, and I appreciated that.<br />
<br />
There will be days, I know, when I will doubt whether I'm suited for this job. On those days, I predict I'll feel like I'm rubbish at it and I'm better off doing something else. Something easier.<br />
<br />
On those days, I'll need to remember that more often than not, I do get things right. As for the rest of the time... Well, I can only get better.<br />
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After all, 'Ancora Imparo'.kkhalilrhttp://www.blogger.com/profile/07210124426451234275noreply@blogger.com0tag:blogger.com,1999:blog-1389601006629757658.post-73804782972201590572013-01-15T19:36:00.001+11:002013-01-15T19:36:26.664+11:00RockstarI'm completely burnt out, but I've had a fantastic day.<br />
<br />
I had antenatal clinic in the morning (first time I've run them, but it went beautifully and I love them now!) and saw general patients in the afternoon.<br />
<br />
Just like yesterday, every case was different and I had no way of preparing for what came next.<br />
<br />
I know it's my second day, but today seemed to go on for so long, it feels like I've been doing this forever! Except for my lack of experience with most things, which hopefully will come soon enough.<br />
<br />
I love my patients. And my supervisor. And the nurses. And the admin team.<br />
<br />
To say the least, I'm having a ball! I'm just so drained at the end of the day. I've had enough, but guess what... I've got to go back in tomorrow! And the day after that. And the day after that.<br />
<br />
Welcome to working life... 😱<br />
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In other news, my supervisor called me over after clinics today for a debrief and told me how impressed she's been by my performance and my rapport with my patients. And, in response to me being a Rockstar Intern, she's going to double my patient load.<br />
<br />
My first thought was, 'Yay!'<br />
<br />
And then I thought, 'What am I thinking? DOUBLE load???'<br />
<br />
On one hand, this is an immense compliment. I'm honoured that my supervisor feels that I'm capable enough to tackle this. This will be an added challenge for sure, and if I were to be entirely honest with myself, I feel up for stretching a little bit beyond my comfort zone.<br />
<br />
However, I feel a little stretched already, even with my current workload. I'm feeling it. The past two days have been exhausting.<br />
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I suppose one can only try, right? I'll do my best, see how tomorrow goes, and if it works out, I might be on my way to becoming the most productive intern the clinic has ever seen.<br />
<br />
Well... That's the plan, anyway!kkhalilrhttp://www.blogger.com/profile/07210124426451234275noreply@blogger.com0tag:blogger.com,1999:blog-1389601006629757658.post-72202153087025038932013-01-14T22:08:00.001+11:002013-01-14T22:08:13.437+11:00What Have I Gotten Myself Into?...As much as I love General Practice, starting my medical career on a General Practice rotation is quite possibly the most difficult thing I have ever done.<br />
<br />
When you start out on a ward in a hospital rotation, you get orientated to the ward and procedures and routines, and although it may take you some time to get your head around everything and get into the swing of things, with a little help from your more experienced colleagues, you eventually find you groove.<br />
<br />
With General Practice however, nothing and nobody can prepare you for what's about to come through the clinic doors. Because nobody knows.<br />
<br />
The day-to-day variations is one of the more wonderful and exciting things about General Practice. However, when you're a junior doctor on your first day of practice out in the real world, the last thing you want is variation. Instead, you crave stability, dependability, and reproducibility; all of which are absent in GP-Land, where every patient you see is an entirely different clinical conundrum.<br />
<br />
Today, I went from seeing a geriatric patient to a paediatric patient to a patient with a fractured foot to a patient with a skin lesion to a patient with reduced hearing to a patient with leukaemia. No pattern whatsoever. No way to prepare for what's to come.<br />
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All I can say is, by the end of this 20 weeks, I've got no choice but to become a phenomenally outstanding clinician.<br />
<br />
This is it. It's sink or swim time.kkhalilrhttp://www.blogger.com/profile/07210124426451234275noreply@blogger.com0tag:blogger.com,1999:blog-1389601006629757658.post-7767451584034471332013-01-13T22:50:00.001+11:002013-01-13T22:50:03.531+11:00Driving It Home2013 for me so far has been all about change.<br />
<br />
1. I have a new job and will now need to get used to saying 'Doctor' instead of 'Medical Student' (Harder than it looks...)<br />
<br />
2. I am getting paid* (Say what?!...)<br />
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*See item 1<br />
<br />
3. I am getting paid for something that I love doing and would much prefer to be doing for free because it somehow takes a bit of the pressure off (But unfortunately, it's harder to work in this business for free than it is getting paid for it)<br />
<br />
4. I have relocated to a place that is 6 hours away from everyone and everything I've come to know and love in the last 4 years<br />
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5. I have a driving licence* (and thus am now legally allowed to make a nuisance of myself in said new place)<br />
<br />
* A necessity due to said new job and new town<br />
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There are days when I feel like I've been thrown into the deep end and its pretty much 'sink or swim'.<br />
<br />
Thankfully, I'm swimming. So far.<br />
<br />
In the past 5 days, I have gone from zero driving experience to 1000kms and counting, owing to the fact that my orientation week was held at two different locations 45 minutes away and I've had to do some significant back-and-forths.<br />
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Don't get me wrong, I've actually enjoyed the experience. Even my first solo drive, in which I got lost and spent 3 hours getting to a place which should have taken me 45 minutes to get to, was enjoyable. I've decided that I like driving in the country.<br />
<br />
Other than this nasty virus I've caught (which I've spent the last 48 hours trying to get rid of and hoping to be rid of it in the next 12 hours in time for my first official day of real work), things have been going pretty good.<br />
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Everyone I've met here so far has been so lovely and welcoming; I have no doubt I'll enjoy working here.<br />
<br />
So here's to changes - Onwards to new adventures!kkhalilrhttp://www.blogger.com/profile/07210124426451234275noreply@blogger.com0tag:blogger.com,1999:blog-1389601006629757658.post-2397461297165017262013-01-09T17:53:00.001+11:002013-01-09T17:55:38.220+11:00Newly MedsIt's Day 3 of me being a doctor but so far, I still haven't felt like a doctor.<br />
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Not that we've done too many 'doctory' things just yet.<br />
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As part of the Murray to the Mountains Internship Programme (which is by far the best medical internship programme in Australia, in my humble opinion), my fellow interns and I (there are 5 of us altogether) get a full week of orientation before we officially start working as doctors.<br />
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In the past 3 days, we've covered introduction to our respective health services/departments (we all start out on different rotations) and the programme itself, and attended several workshops and lectures covering topics like advance care planning, clinical skills and drug chart documentation.<br />
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Despite being extremely full on and thus mentally exhausting (particularly since my brain has had to be roughly dragged out of holiday mode), these lessons and refresher courses have been extremely valuable. I'm very thankful we've had them.<br />
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The one thing that's probably glaringly different about the M2M orientation compared to other internship programmes is the fact that the activities are held at different sites and hence, there's a lot of driving involved.<br />
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On that note, I'm just about to drive from Wangaratta to Yarrawonga for our Intern-Supervisor dinner, I should probably head off and continue this later!kkhalilrhttp://www.blogger.com/profile/07210124426451234275noreply@blogger.com0tag:blogger.com,1999:blog-1389601006629757658.post-60929138203467376502012-12-08T14:37:00.001+11:002012-12-08T14:37:40.100+11:00The Skinny on Obesity (playlist)<iframe allowfullscreen="" frameborder="0" height="344" src="http://www.youtube.com/embed/videoseries?list=PL39F782316B425249&hl=en_GB" width="425"></iframe>kkhalilrhttp://www.blogger.com/profile/07210124426451234275noreply@blogger.com0tag:blogger.com,1999:blog-1389601006629757658.post-48302209055150344452012-12-08T12:54:00.001+11:002012-12-08T12:54:50.966+11:00Sugar: The Bitter Truth<iframe allowfullscreen="" frameborder="0" height="344" src="http://www.youtube.com/embed/dBnniua6-oM?fs=1" width="459"></iframe>kkhalilrhttp://www.blogger.com/profile/07210124426451234275noreply@blogger.com0tag:blogger.com,1999:blog-1389601006629757658.post-36531543265179160992012-12-05T21:41:00.001+11:002012-12-05T21:41:29.988+11:00Great Things"It has been a pleasure sharing the journey through med school with you, and I know that you will go on to do great things..."<br />
<br />
Such a simple statement from my friend Ruth and yet, it meant so much to me.<br />
<br />
From where I stand right now, I can't see what's ahead of me. I certainly can't see any "great things".<br />
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And yet, something about her statement alludes to the potential of great things to come. Something in her statement gives me hope.<br />
<br />
I suppose the lesson here then is, never underestimate the power of a few sincere, well-chosen, kind words.kkhalilrhttp://www.blogger.com/profile/07210124426451234275noreply@blogger.com0tag:blogger.com,1999:blog-1389601006629757658.post-75715664599935428682012-12-04T19:24:00.001+11:002012-12-04T19:24:56.864+11:00The Morning After...As we were driving through this little town where I will be starting my first 20 weeks of internship next year, I looked around at the towns people walking about and thought... These are my patients.<br />
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It's the most awesome thing. It's finally happened and I'm finally here.<br />
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Sure, I'm still learning. And as a doctor, I always will be. <br />
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But this will be where all the magic happens. This town... These people... They will be my first adventure.<br />
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And you know what?<br />
<br />
I can't wait to get to know them all.kkhalilrhttp://www.blogger.com/profile/07210124426451234275noreply@blogger.com0tag:blogger.com,1999:blog-1389601006629757658.post-62320137905743964742012-12-02T22:08:00.001+11:002012-12-02T22:08:25.337+11:00The Night Before...Through the trusty rectrospectoscope, my final year of medical school is looking more than a little bit blurry.<br />
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However, amidst the chaos and confusion, I've managed to retain a few solid gold principles which I hope will take me through my internship year.<br />
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1. Take ownership of all that you do - it'll help you feel like you know what you're doing, even when you're still trying to figure it out<br />
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2. Everyone started out somewhere - So when you feel like you're at the bottom, rest assured that the only way left to go is up<br />
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3. Be safe, seek clarification, and ask for help<br />
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4. Everyone, even The Legendary Professor John Murtagh, feels nervous - Conquer your fears through rationalisation and by managing your expectations<br />
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5. Keep on learning, listening, trying, and believing in yourself - A little perseverance goes a long, long way<br />
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My father once told me, "Picture a cat. Toss it out a window, and it lands on its feet - despite never having to anticipate being thrown out of a window."<br />
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If there is one thing that I'd like to learn before the start of next year, it's the art of Resilience.<br />
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But then again, I'm still here. I'm still standing.<br />
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Perhaps that's a start.kkhalilrhttp://www.blogger.com/profile/07210124426451234275noreply@blogger.com0tag:blogger.com,1999:blog-1389601006629757658.post-38402498059678704362012-10-31T16:54:00.001+11:002012-11-16T11:30:39.826+11:00Elizabeth Gilbert: Your Elusive Creative Genius<div style="text-align: center;"><iframe allowfullscreen="" frameborder="0" height="270" src="http://www.youtube.com/embed/86x-u-tz0MA?fs=1" width="480"></iframe></div><br />
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At present, I am struggling to write an article for publishing, after an incredibly long hiatus.<br />
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My writing brain feels atrophied. It feels like my genius has left me.<br />
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Something that used to come so naturally, now feels forced and staggered.<br />
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Inaccessible, unattainable, just barely out of my reach - but I know it's there, and that's what frustrates me.<br />
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But the more I try, the more I feel like I'm making progress. I'm finding my way back and opening up inwards.<br />
<br />
When I was much younger, after writing a song or a poem, I would often look at my work and feel that I'm looking at something that I did not create, but instead, something that was already in existence all along, just waiting for me to pen it to paper.<br />
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And in that realisation, I would feel like a puzzle piece; part of a larger whole. I felt both humbled and honoured to be part of this bigger picture.<br />
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Over the years, one of the most important things that I've realised about writing and my other creative pursuits is this. <br />
<br />
As with all things, perfect practice makes perfect. There is no shortcut to this rule, regardless of whether you're 13 years old or 31 years old.<br />
<br />
This means, that if you have a skill that is important enough to you to want to excel in, you have to make time for it. You have to work at it, and you have to perfect it. Use it or lose it.<br />
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When I first enrolled into medicine, I promised myself that I would retain my literary and artistic skills throughout my course. What I didn't know then that I know now is just how difficult it is to do that.<br />
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However, letting that part of you atrophy is dangerous. You lose so much from it; most important of which is your sense of self.<br />
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What I'm learning at this stage of my life is to now and then take myself away from medicine and nourish my little genie. <br />
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And, in the long run? I have no doubt that I will be a better doctor for it.kkhalilrhttp://www.blogger.com/profile/07210124426451234275noreply@blogger.com0