Light at the end of the tunnel?

Sisyphus, Netherlands (2008)

I totally understand if you have a strong opinion about the validity of social media like Twitter or Facebook. Sure, I used to think that Twitter was just another way for Paris Hilton to inform the world that she was like totally digging her new colonic irrigationist.  And Facebook might be a questionable way to delude yourself into believing that you actually do have 200 bestest buddies. I have now embraced both (I’m still apprehensive about Google + and LinkedIn) with alacrity totally unsuitable for a shy reserved person like myself. Anyway, if you are not on FB or Twitter you would have missed the announcement that I apparently was deemed competent enough to practice medicine. In other words, I passed medical school.

I remember shrugging my shoulders when I received my email. How do you celebrate the end of 8 years of studying? Especially when the further you dig the more you realise that the real hardcore learning is still ahead. The giddy excitement of wearing a stethoscope around my neck in the first year has long since given way to hastily shoving it in my bag as I hurry home from the hospital.

So what’s next? That’s kind of awkward: I’m no longer a medical student but I’m not yet a doctor (there goes my plan of booking the airline tickets to NZ under a new title!). I’m a Print student, a.k.a. Pre-Internship student. I’m attached to a general medicine team in one of Sydney’s hospitals and my only purpose is to prepare for future everyday life as an intern. And it’s far from glamourous, folks. Long ward rounds with consultants where your main job is that of a glorified scribe (taking down every word of medical wisdom, no, I’m not being sarcastic), becoming a detective tracking down patients’ records, their doctors, their previous operations and their family; writing discharge summaries, ordering tests, requesting consults, taking bloods, inserting cannulae, catheters and other pieces of equipment into patients’ bodies. No more lectures, no more trying to impress the examiners and not very much brain work compared to the life of a student.

As an aside, I did my elective term in the US and I saw medical students being expected to do all of these routinely in their 3rd and 4th year. In the Australian system medical students are somewhat “mollycoddled”, i.e. left to our academic devices. We are expected to focus on taking a history, examining the patient, formulating a differential diagnosis, coming up with investigations and a comprehensive management plan. We are kindly spared from the actual practical implementation of most of the above. Sure, we can do basic bloods and procedures but nobody would let us near a pediatric lumbar puncture. My jaw hit the ground when I saw a 3rd year perform one in the States. I was jealous and terrified at the same time. You choose what system you prefer. I might do a separate post on this later.

After 8 weeks of mostly paperwork I will be moving 5 hrs north of Sydney closer to the hospital where I am allocated for the next 2 years. I’m looking forward to the work, responsibility, earning money (hell yeah! after so many years!) and spending my limited spare time on the beach in one of the most beautiful spots in Australia.

If you are wondering how medical students turn into baby doctors then turn into big doctors, then specialise, then superspecialise, then earn bucket loads of money and buy a yacht (hahahahaha I wish), let me break this down for you.

Here is an overview of a graduate* pathway into medicine in an Australian system:

*undergraduate medical school requires an insanely high UAI + UMAT score (Undergraduate Medical Admissions Test) and a sheer determination to avoid any social life in your teenage years. The plus side is that it cuts down your Uni time to 6 years. 

3-4 years – Undergraduate degree: a happy slightly drunk student with not a care in the world
4 years – Medical school: a conscientious medical student with little social life and few friends who don’t do medspeak
* I’m here!
1 year – RMO1/Intern: paper work, routine hospital care, finally money! but no time to spend it, no friends
1 year – RMO2 /Resident: more paperwork, more routine hospital care, more money, a few friends with the same attributes
*At this point if you are lucky you may get into a specialty training program like Basic Physician training. However, for some of the more popular specialties you might have to hang around the hospital as a SRMO (senior medical officer) for a few more years, sorry!

4-8 yrs – Specialty training/Registrar: the time in your life when you know the most about the most of general medicine/surgery. Glamourous but hardworking creatures.
1-2 years – Fellowship/Fellow: All the ones I have met look lovely but aloof, only joining the conversation when their particular area of interest is discussed.
*Hopefully by this time there will be a hospital position available. If not, you might go and do a PhD. Or a Masters. Or take up knitting. 

The End – Consultant/Specialist: You are now officially allowed to wear a suit and ask medical students deep and irrelevant questions about medicine, theatre and religion. I’ll get there one day, hopefully before my hair goes grey.

Get your calculators ready: this makes on average 12-16  years from the start of your first uni degree till you are fully qualified as a specialist. If you are a woman who wants to have children you have to factor in some maternity leave. Somewhere. Anywhere.

The General Practice route (family medicine) and Paediatrics are a little different as you can enter into the training program as an RMO2 and generally finish in 3-4 years after that.

For the record, I AM very excited about finishing medical school. However, don’t rush to book an appointment with this new doc yet As you can see I have a long road ahead.

Stuff that you need for finals…

First I’d like to thank everyone who left comments, messages and tweets following my daughter’s guest post. As I have mentioned before, kid Paleo (or any kid diet sans soft drinks, pizza, brightly coloured boxed non-food and protein generously covered in flour and fried in industrial oil) can be a very lonely place to be. Michelle was ecstatic to receive so much support. Her guest post ended up being my most popular post to date (I’m not sure whether it’s a reflection of her eloquent writing or my own nerdy articles). Needless to say, she will be invited for another guest spot.

Secondly, I will be taking a 2-week break from blogging. My final medical school exams are just over a week away and I’m finding it really hard to concentrate on anything else. It’s a slightly scary prospect that the last 4 years of medical school and the preceding 4 years of undergraduate studies have come down to 375 questions (I think) over 3 days. Sounds grossly inadequate somehow.

So how do I prepare to cover the whole of medicine, surgery, obstetrics, family medicine and critical care? (I did my pediatrics and psychiatry assessments last year). Well, I think that a week before the exam is not the time to learn. I have this weird sensation that my head is officially full and any attempts to fit any more information inside it will result in epic loss of all existing data. And seriously, if you don’t know it by now you’ve left it a bit late. So the plan for the next week is to focus on the information retrieval process, i.e. plenty of practice papers and dummy questions. And in case you are wondering, here is a fraction of what I am actually supposed to know.

Wish me luck. I’ll still be available on Twitter for some light-hearted distraction (sad, I know). I am not nervous, yet. I feel quite at peace with the thought that if I do fail I can always go into full-time blogging. It seems like a pretty cool gig.

See you in a couple of weeks.

Love thy patients, or How to pass medical school

Today I had the first of many exams coming up in the next 2 months heralding the end of med school. Apart from being extremely nerve-wrecking it is also very exciting because you can literally see the light at the end of a very very long tunnel.

Long case examination is an old tradition in Western medical education. In Australia the long case is used to test both final year medical students and candidates at the FRACP examinations (doctors training to be specialists in internal medicine).

The main challenge and the objective of the LC is to demonstrate your clinical skills, or in other words, how you can apply all that book-learning in real life. Knowledge alone won’t get you far in the long case (or in medicine itself). That is why the long case is said to be a skill and an art form.

The exam itself is normally conducted in a different hospital to prevent students from being familiar with patients. On arrival into this hospital I am allocated a patient who has been previously examined by a senior doctor. This doctor, who will be my examiner, has also been familiarised with the full story of the patient’s diagnosis and treatment. I am to spend 60 mins one-on-one with my patient with no notes, blood results or imaging at my disposal. In an age when we seem to treat numbers rather than patients it seems almost anachronistically refreshing.

My goal is to get the history of presenting complaint (it’s advisable not to frame it in those terms otherwise you might get a lecture on the quality of food in the hospital), past medical history, medications, social history (smoking, alcohol, home situation) and the history of any medical conditions in the family.

At this point I am supposed to have a few ideas in my head as to what is happening. This should in theory guide my examination in the right direction. But if you still have no clue you might as well examine everything, time permitting. Sometimes you get lucky and the patient knows the drill so well they give you advice on what to do next (“Hey, love, docs normally use that funny hammer for my reflexes too”). Although if somebody suggests you do a prostate check for no reason you should probably refrain.

After 60 mins the bell rings and I have to say goodbye to my victim. 20 minutes is then allocated to arrange my thoughts on paper. And then the fun part begins: a 20 min presentation to the examiners which includes a compulsory 10 minute “grilling” time. I am supposed to condense my 60 mins with the patient into a brisk 10 minute recital which includes:
– only the relevant clinical information (missing out on that fascinating story about Aunty Selma and her rash)
– identifying the patient’s main issues which is a lot harder than it sounds. They might be concerned about their wedding ring stuck on the finger while in florid heart failure.
– my feeble attempt at probable diagnoses (or Dr House’s “differentials”)
– my suggestions on how to investigate these issues. Sending bloods off for EVERYTHING will not get me any points. Cost and common sense require justification for every test. At least in the exam.
– my management plan. This has to address every medical and every social issue. It might sound a little interfering but I am expected to come up with strategies to cope with the social isolation in the elderly. I suggested bingo nights.

Long case undoubtedly gives you the skills to cope with most clinical problems. But the best part about this exam is the people. Unlike the impersonal case histories in our written tests, we get to spend a whole hour with a real person. And real people are fun. They may be humourous, aloof, rude, obliging, too talkative, not talkative enough. You feel thrown in the deep end and willy-nilly you have to swim. You can read a whole book on rheumatoid arthritis but until you sit down with a fluffy old lady who had to give up knitting because her fingers are not as nimble as they used to be, you will never appreciate these little details.

In my student life I have done dozens of practice long cases. You learn to be succinct but empathetic, quick but thorough. Sometimes patients say no to students. I can understand that. You have been poked and prodded enough, you might have just received a bad diagnosis and this awkward-looking young person is a bit of a nuisance. But what if you knew that your particular condition will always evoke a memory of YOU in my head? I will not remember that chapter in a medical textbook but I will forever remember my first case of Crohn’s 3 years ago: a lovely 30 year old lawyer who had to bravely describe her bowel habits to a group of 5 students, me the only female.

It’s fashionable to dismiss doctors nowadays. Yeah, I know, we have screwed up. We plug the conventional wisdom, give pills like candy and believe the rubbish from pharmaceutical companies. But whatever your experience with the medical profession, teach me what you want me to know. These annoyingly inquisitive medical students and junior doctors are your chance to change the system for the better.

Oh, and they shook my hand and said “Well done” at the end. I guess I passed.

 

 

The mind boggles…

Hello, my name is Anastasia. It’s been 32 days since my last nutrition rant. I thought I had everything under control. I was calmly writing a huge post on polyunsaturated fatty acids. It came out of the blue. I walked into a scheduled lecture on major clinical concepts surrounding diabetes naively believing I had the willpower. Those of you watching me implode on Twitter know just how wrong I was.

The endocrinologist who was standing in front of us is probably a fantastic doctor. He was just asked to help some medical students revise the clinical approach to Type I and Type II diabetes. I cannot judge his level of knowledge or his expertise based on a few slides. But maybe you can.

After briefly recapping the definitions of Type 1, Type 2 and LADA (late onset autoimmune), he got my attention by declaring that Type 2 Diabetes was a genetic condition. I was a bit flummoxed. Sure, I know of the studies isolating the genes involved. I also know of the popular quoted statistic that the identical twin of a diabetic patient has 90% chances of getting the disease. Still I think of Marfan’s or hemophilia as a typical genetic condition: a known mutation of a certain gene causing a problem.

The next important fact to be addressed was the increase in the prevalence of diabetes. I thought you had to have spent some serious time under a rock not to have noticed that but nevertheless I observed many students scribbling furiously.

At this point I was getting a little confused: why would a genetic condition increase in prevalence in such a short period of time? The answer was on the next slide.

Causes of increasing prevalence of T2D:
– increasing gene pool
– obesity
– high fat and high GI diets
– less physical activity

“Increasing gene pool” had me slide down my chair in a fit of silent giggles as I was mentally fighting off in a image of all those sex-crazed diabetics hellbent on spreading their defective genes.

And you all know how the obesity story goes: being a glutton and a sloth makes you fat. Being fat makes you a diabetic. Hang on, wasn’t it genetic? I’m lost.

This disease is so horrible that if you are thin then it’s your genes, and if you are fat then it’s your fault!

So is there any hope???

Here is a long awaited lifestyle slide:

1. Refer to a dietician for diet advice.
Good to know that we as doctors are prepared to admit that we are totally inept in giving diet advice.
2. Lose weight.
If only somebody ever told a fat diabetic that all they have to do is to lose weight! They wouldn’t have had years of silent small vessel damage destroying their retina, eyes and kidneys.
3. Maintain physical fitness, eg walking 30 minutes a day 5 times a week.
My sarcasm has actually failed me at this point. I honestly have nothing.

The discussion on the lifestyle changes for diabetes was pessimistically concluded with: it’s too hard to convince patients to change their diet and increase their physical activity. The lecturer sounded genuinely upset about this fact, lamenting that most lifestyle changes tend to fail, at which point all diabetics inevitably progress to medication.

Ah, yes, the medication. Quick rundown on the drugs: from metformin (“a fantastic drug which assists with weight loss and improves the liver insulin sensitivity”) to sulphonylureas (“fantastic drugs with a proven safety record which increase the insulin output from the pancreas”) to glitazones (“recent drugs exciting some cautious optimism, still associated with some unfortunate side effects, like HEART FAILURE”) and so on. Until, finally, insulin. All roads lead to Rome, all drains lead to the ocean. All diabetics end up with insulin.

Apparently, the trick with insulin is not to forget to increase the dose when you know that you are about to shock your system with a gargantuan serving of pasta with a low fat sauce. Silly me, I would have thought it sensible to reduce your requirements for insulin in the first place.

And of course as any medical student knows, a discussion on diabetes has to be wrapped up with some happy snaps of gangrenous toes. That will drive the message home!

I know that many of you are reading this with a mixture of exasperation and amusement. And a shadow of superiority. Surely any intelligent person would critically appraise the information given, research the best sources, analyse primary studies, draw their own conclusions and use their own brain???

What if you are a medical student? You have 5 months till people call you “Doctor”.  You need to be able to deal with trauma, haemorrhage, heart attack, delirium, burns, sepsis, anaphylaxis, organ failure, psychotic episode, dislocated shoulder, meningitis, testicular torsion and a spider bite.

Senior doctors inspire our admiration with their wealth of knowledge, confidence in dealing with the unexpected, their people skills (not always) and the sheer fact that they have been through what we are going through and survived! Even if you were crazy enough to start a nutrition blog in your last year of med school, do own research on the train to the hospital and write angry posts instead of studying for exams… would you question an esteemed professor during his lecture?

Everything we know is just what we have been told. Based on that, the future of medicine has me worried.

I am eagerly awaiting your comments.

Medical degree = nutrition knowledge??

You are tired of diet contradictions in the media. You have had enough of celebrities who are “half their size! Learn how they did it!”. You have done your own research and now you are going to your family doctor, because you want answers. So, Doctor, is 1.5 g of protein per kilo enough for me if I am doing intervals and strength training 3 times a week? What do you think of Omega-3 composition of grass-fed meat vs grain-fed? How do I reduce my body fat while maintaining muscle mass and strength? You are getting a blank look. The eyes are glazing over. A hesitant hand reaches for a referral pad to a dietician…

Hey, they are doctors! They wear white coats and have stethoscopes around their necks! Don’t they learn this stuff? Let me tell you how much education on nutrition we ACTUALLY get in medical school.

Year 1. The age of innocence
– a lecture on triglycerides in diet. It details the cholesterol transport in all its chemical formulaic glory and exciting medications like statins which we can use to disrupt this process.
– one of the cardiology lectures briefly mentions that saturated fat and cholesterol cause coronary heart disease. A graph from Framingham heart study is flashed on screen. We are assured that it shows a relationship between blood cholesterol levels and heart attacks.

Year 2. Depth of lecture boredom
– endocrinology block introduces hormonal regulation of metabolism. A very dry and boring biochemistry lecture describes the relationship between insulin and glucagon.
– a couple of lectures by an obesity specialist. She talks about different strategies used for obese populations: high vs low carb diets, very low calorie diets, lap band surgery, behavioural strategies, more drugs. At the end she pessimistically concludes that none of the above work in the long term
– a very exciting lecture by Jennie Brand-Miller. She concedes that obesity is probably related to metabolic syndrome, mentions the role of carbs in developing insulin resistance. Then she enthusiastically talks about her research in glycemic index. We are told that to reduce the incidence and severity of diabetes we should recommend low GI diets. The lecture concludes with the slide of her book.
– a few lectures on diabetes management with a focus on medical (=drug) treatment.

Years 3-4 Unleashed onto unsuspecting public
Ahem. Nothing.
Oh, I got presented with a free patient and doctor information booklet on diabetes during my general practice rotation. It is written in a very clear, easy to understand language, colourful pictures, graphs and all. It is written by Pfizer, the pharmaceutical developer of Lipitor, the cholesterol-reducing medication which brought its happy executives $12.2bn in 2005.

 Does anybody else think that this is a bit like a car mechanic who blindly swears that he found a mechanical fault with your car and now you have to pay him $x to fix it? (I normally pay just in case because I don’t understand half of what he is saying and I am a little scared of all this stuff under the bonnet).

 Other than these delightful handouts from pharmaceutical companies, we are encouraged to visit websites like the Heart Foundation, the organisation which has just given its tick of approval to Milo cereal. ‘Nuff said.

Yes, there are others, who study nutrition in order to help their increasing (in size) patient population. But their knowledge is the result of a conscious effort, not an automatic consequence of a medical degree. They are worth their weight in gold when you find them. Because apart from being diet-savvy, they clearly possess humility to acknowledge what they don’t know.

 So what does your doctor know about nutrition?

 Disclaimer: other medical schools might provide more teaching on lifestyle modification. Also, I might have had a microsleep in one of these lectures and missed some pearls of nutritional wisdom. This is not intended as a personal attack on any individual physicians. This is merely an illustration that unless doctors are interested enough to search for truth themselves, you are getting second-hand information.

Welcome to primalmeded

I am a final year medical student and I have a confession: I know precious little about health.

 

I have been taught about the mechanisms of heart attacks. I know how to diagnose one, what medications to prescribe, what complications to expect and how to look after my patient on the cardiac ward. The patient gets better, I discharge them home with a list of medications, a referral to a cardiologist and strong advice to “address lifestyle factors”. This is where things get a bit tricky.

 

I used to know what to say: avoid saturated fat, exercise up to 150 minutes a week, reduce your cholesterol, avoid salt, eat plenty of whole grains… But somehow “lifestyle modification” remained this vague elusive concept. Doubt made me get off my butt and do my own research.

 

My partner says that after I read Gary Taubes “Diet Delusion” (“Good Calories Bad Calories” as it is published in the US) I went quiet for a week. I hated the way that book made me question everything I thought I knew. I struggled through it and then promptly read it again. I began ferociously searching for information on nutrition and exercise. I still am.

 

There are people out there who are much smarter than me. They refuse to accept the nutritional dogma of the last 50-100 years which led us to be the fattest and unhealthiest generation yet. I will endeavour to follow their example and take charge of my medical education.

 

This blog is to share my ideas with you: my friends, family and anybody else who is tired of the latest gimmick and the newest fad. And to put my money where my mouth is, I promise to share my personal journey to health and fitness. Please do not expect “before and after” bikini shots, it ain’t gonna happen.

 

Drop me a line if you like what you see, or maybe two lines if you hate it.

 

Thanks,

Anastasia