Di stress / Distress / De-stress

Please enjoy this post I wrote 2 years ago while struggling to survive my intern year. The level of optimism is truly remarkable considering I was on my Paediatric rotation at the time.

The shift from medical school to internship is the shift from dipping one’s toes in the swimming pool to diving in the deep end. When you’re a medical student, duty ends at 10pm. If you can’t get an intravenous access, you call the intern. 12 o’clock is always lunchtime.

Suddenly, it’s July 1 and the minutes don’t roll over. Free paper has been burnt. You have passed the dreaded MBBS and received, in return for your labours, more hard work. Harder work, in fact. Your duties extend for 24 and 48 and 56 hours. Sleep becomes a concept. Lunchtime, a luxury. You become the person the medical student calls when they’ve destroyed all the veins in their quest for an IV access.

Why am I here again?

If you haven’t asked yourself that question at least once in the last six months, consider yourself lucky. You might actually want to try your hand at the Lotto.

If there was a buzzword for internship, disillusionment would be it. When asked what lessons have been gleaned from the “Internship Experience”, one intern from a hospital which shall remain nameless (we’ll call it the Really Tall One) responded with an outburst,

“Old doctors want our experience to be as frustrating as theirs to ‘build character’.”

You know it’s time for a paradigm shift when you point out workplace inadequacies and your boss responds with,

“You merely adopted high patient loads and low resources. I was born in it, molded by it. I didn’t have the luxury of readily available investigations until I was already a SR and by then it was an insult to my clinical acumen.”

It’s admirable to want your interns to be the best they can be but there are practices in medicine that in any other profession would spark the ire of an entire HR department. But I digress. This isn’t meant to be a call to arms.

Sometimes the answer to that ever-present question is positive. Real life patient care (as opposed to the dabbling that’s done in medical school) can be and has been rewarding and invigorating. The General Surgery rotation is particularly satisfying in this regard: patients enter the hospital bleeding, broken, dying and with the flick of a scalpel, the swish of a stitch (and some strong pain meds) they survive to maim themselves (or someone else) another day.

Lest this turn into a clichéd trope about the satisfaction of a job well done, I do have some misgivings about the surgical field. Once a patient expressed their profuse gratitude for having their infected digit amputated. You’re . . . welcome?

As uplifting as those moments are, they seem to be outweighed by the downsides of working in the public system. Like McGyver and Miss Lou, you has to tun yuh hand mek fashion. Whether it’s performing an entire sepsis screen (including lumbar puncture) on a neonate without assistance or manoeuvring a 250lb patient with bilateral skeletal traction off their stretcher and onto the CT machine, provided the CT machine is working. One disadvantage faced by every public hospital is inadequate funding, but necessity is the mother of invention. If you haven’t made an IV drip stand out of a curtain hook or a chest tube out of a Foley catheter, you haven’t really lived.

There is a certain satisfaction to seeing patients managed conscientiously despite low resource settings, but can medicine be equally reward and punishment? Ours is the lot of sleepless nights, thankless hours and the constant threat of occupational exposure (latent TB, anyone?). Is the smile of a mother when you tell her yes her baby can go home really worth the stress of q4hrly bilirubins?

As the most junior member of the medical team that stress of ‘getting it done’ rests squarely on the intern’s shoulders. It often feels like we’ve been left in the deep end of the pool to sink or swim, complete with Yoda-like figure declaring “do or do not, there is no try”. Coping mechanisms become currency as we try to stay afloat despite the setbacks. Periodic nervous breakdowns, the impenetrable veneer of cynicism and a strong tendency toward smoking and alcohol are only a few of the methods employed.

If you are stranded amidst the sea of disillusionment, clinging to the battered lifeboat of responsibility it helps, I think, to remember the reason you started out on this journey in the first place. Sankofa, my friends. It is okay to look back for that which you have forgotten. Whether it was the personal fulfilment you get from helping other people or the determination to be consultant someday, internship is decidedly BYOM. Bring Your Own Motivation.

At six months in we’ve already committed to this gestation period, for better or for worse. And when we are delivered in another six months, freshly registered and happy to be out of the frying pan of internship, we’ll look back from the fires of Senior House Officer year with the same clouded nostalgia as the consultants who believe that their internship experience was the only one worthwhile.

The more things change, the more they remain the same.

 

What is a CRH Internship like?

So here we are, one year out of medical school. Internship is behind us and we’re venturing out into the world of fully registered medical practice. And the question one everyone’s (no-one’s) mind is, what is internship at CRH like?

Internship anywhere in Jamaica and the Caribbean is rough. The high patient load and typically low resources keep our clinical practice particularly inventive, and adhering to evidence based medicine is a lot like playing whack-a-mole (just when you think you’ve hit the nail on the head, it’s disappeared and you have to try again).

I chose CRH for my internship for a number of reasons. Montego Bay is my hometown. Because it’s a Type A hospital we see more complicated cases and therefore get more clinical experience. Compared to the other two Type A hospitals, the patient load is a balance between overwhelming and nonexistent and the staff are (for the most part) approachable.

Surgery, Internal Medicine, Pediatric Medicine and Obstetrics & Gynaecology share the same basic traits no matter where in the world you practice. What I have found different is the slant of intern duties. In my opinion, a CRH internship gives you primarily clerical experience. Any additional medical experience is dependent on the interest and enthusiasm of the individual intern.

Broadly speaking, the intern’s job is to see or SOAP inpatients every morning, round with the consultant, carry out requested procedures and tests, and follow up the results of these tests and act on them. Variations of this theme can have the intern seeing or clerking new patients in the Emergency Department, making interdepartmental referrals, organizing procedures off the compound, administering medication etc etc.

At the end of the day the intern’s is tasked with making sure the patient gets whatever they need to get better and get out of the hospital.

A lot of your time is going to be spent writing request forms, writing referral forms, writing notes in the docket and writing orders for medication. Your practical procedures will primarily involve phlebotomy and placing intravenous accesses. There will be times when you don’t feel like a contributing member of the team and there will be times when you’re the one leading ward rounds. There will be plenty of opportunities for learning, and in the same breath you will feel stifled by your supervisor when they only want you to be a scribe and a gopher. Brush these moments off and look for teaching moments. They’re not always obvious, but you can learn something from everyone.

Surgery

On the Surgery rotation, interns spend six weeks in General Surgery and six weeks in a surgical specialty such as Urology, Orthopaedics or Paediatric Surgery (Neurosurgery didn’t take any interns at the time). There’s a lot of hands on experience to be had here, participating in major and minor operations like laparotomies, appendectomies and the ever-frequent digital amputation. It’s impossible to leave this rotation without knowing how to suture and the basics of pre-op and post-op care, especially since the intern is the one leading the ward rounds, the one with primary management of inpatients.

Paediatrics

Paediatric Medicine divides your time in two six week blocks of the paediatric ward and the special care nursery. Here you learn attention to detail, the importance of acting on the results of investigations and how to handle stress. While on paediatrics you pick up skills in lumbar puncture and intravenous access placement, medication administration and infection control. Interns on Paediatrics are responsible for  administering all IV medication, which is something unique to CRH. If this doesn’t sound daunting, it should. The ward capacity is 20 patients (each. For the ward and the SCN), who require medication up to four times per day.

Medicine

Internal Medicine is a straight three month block with no sub-specialization (small chance of getting some Nephrology exposure). Patient load is high, resources are low and most of your patients are frequent visitors to the ED. It can get frustrating, especially if you like ‘saving people’ because the majority of patients are repeatedly sick because they are non-compliant. There are a lot of social and economic reasons behind this non-compliance but tertiary facilities are the ones feeling the brunt of that primary care failure. This is where you hone the twin skills of BLS/ACLS and breaking bad news. The practice of Internal Medicine is roughly the same across the board, with variations in level of academic exposure and access to resources (CRH falls low on both spectra).

Obs/Gynae

Finally, Obstetrics and Gynaecology is the Other surgical rotation, where instead of gunshot wounds and pus filled abdomens you get happy bouncing babies and failed abortions. The scope of your exposure ranges from suturing multigravid vaginal lacerations to contacting the Centre for Investigation of Sexual Offences and Child Abuse (CISOCA) for your 13 year old patient with pelvic inflammatory disease. OB/GYNs balance surgery and medicine remarkably well, with a smattering of paediatrics (neonatal jaundice has to be diagnosed by the OB/GYN intern before referring to Paeds) and the general atmosphere of the department is one of bonhomie. Interns on O&G  don’t have very active roles in patient management (most of the decisions are made by the consultant, with the intern carrying out the orders) and the consultants round daily so you’re never really on your own (pros and cons, here).

Conclusion

CRH definitely has its ups  – interns have the option for on-compound housing, for instance – and its downs – necessary machines get broken, a lot. And at the end of the day the decision about where to do internship is multi-factorial. I wish I could offer a comparison among internship sites in Jamaica or even the wider Caribbean but alas. I’m not so lucky enough to have enough friends in high and low places.

I will say this: no matter where in the island or Caribbean you do internship, almost everyone will be prepping for USMLEs or some other foreign licensing exam. Internship may feel like the worst year of your life (and in some ways, it is) but it’s just a stepping stone to postgraduate qualifications and the start of your actual medical career.

Conquering Duty Anxiety

I really don’t like being on call at the hospital.

Yes, someone has to do it. Yes, we get paid overtime to do it. Yes, this is how we gain experience as doctors. But all of those logical structured reasons fade away when I’m startled awake at 1am by a nurse calling about the patient in cubicle 5 who won’t stop bleeding.

When I was on pediatric medicine I would have a lot of anxiety to deal with on duty. It’s terrifying to be the first responder to a critical situation when you’re not 100% sure you can handle the case. To make matters worse, I was dealing with babies. Delicate (yet somehow also borderline indestructible) little human beings. In the beginning I would have regular panic attacks and palpitations, but as time went on I got more comfortable handling the common emergencies. I became more confident in my abilities, and could usually rest assured that if there was anything I really couldn’t handle, I could call my senior.

The most pervasive part of duty anxiety for me, though, the one that crops up on every rotation regardless of my self-confidence is the uncertainty about being called. You can never tell whether a night will be calm or hectic, whether you will be called ten times in one hour or once for the whole night. And that kind of unpredictability is anathema to me.

As humans we like to think that we have control over our universe. As interns we have all kinds of superstitions for keeping emergency duties light. Knock on wood to keep the bad karma away; when you notice that a night is being particularly uneventful, you can’t say so out loud or you’ll jinx it.  We do these things to try and hold on to the idea that we can dictate how a night will progress just by monitoring our actions.

But letting go of duty anxiety means letting go of the crazy notion that what we do or think will somehow impact the chances of a patient taking a turn for the worse. Or will somehow keep a hundred people from turning up in the emergency department in the middle of night.

It won’t.

The night will unfold as it was always going to unfold, whether or not you stay up having the world’s most intense staring match with your phone, whether or not you knock on all the wood. Whether or not you try to grab a few hours of sleep or comment on how quiet the wards are being. All the superstitions are doing is tricking you into thinking you have some measure of control, so that you think it’s your fault when the emergency duty turns into a madhouse. “I have 3 emergency surgeries because I didn’t knock on wood this morning”.  It sounds completely illogical, because it is. But that’s usually the nature of anxiety.

I have found that the best way to conquer my duty anxiety is to relinquish this idea of control. To let the night progress as it will, without trying to force it into whatever hopes or expectations I might be harboring. When I do that, when I go about my tasks and breaktimes free from the thought that what I’m doing will make or break the night, I find that I’m a lot less anxious and a lot less tired too.

What to Expect when You’re Interning

Internship starts, not with a bang or a whimper, but with a barely noticeable intake of breath. Not a deep breath, a regular resting one. You don’t notice it until you do. That’s the only excuse I have for why there are no entries in my journal until six whole days into my intern year. I will attempt to recreate those first few steps now.

If you’re completely unfamiliar with internship in Jamaica, here is a brief overview. If you already know everything there is to know, feel free to skip this next paragraph.

When medical students graduate from UWI they have already applied to work at one of five several government hospitals (and one semi-private hospital) qualified to supervise medical interns. What follows is a 12 month long, somewhat supervised trek through the four basic clinical specialties: General Surgery, Paediatric Medicine (babies), Internal Medicine (adults) and Obstetrics & Gynaecology. This experience is unique to each hospital (and each intern), but overall we’re expected to emerge from this year with the skills necessary to become a fully licensed medical practitioner. (Don’t worry, nobody tests you on these skills. Which is probably why so many bad less than stellar doctors slip through the cracks).

At my hospital, we received a one day orientation the week before we were scheduled to start working. I think this is the standard. We were introduced to key members of staff (bureaucracy, meh), discussed the housing situation (lacklustre at best), were given a tour of the facilities (too big to walk around without getting tired) and then spent two hours delving into grim and gory details of everyone’s favourite topic: remuneration.

Predictably, the session left us entirely unprepared for the actual first day on the job.

I started my internship in General Surgery and I remember feeling small. Not unimportant, just literally small. Like a child. In final year, patients would laugh when I approached them for procedures, asking if I was still in high school. And here I was not six months later as their doctor, their first point of contact with the surgical team. My first ward round passed in a blur of unfamiliar names, familiar diagnoses and trying to sign my name quickly enough to move on to the next docket.

It got easier. Those patients who were handed over to me left. I got my own patients. My handwriting got quick (and sloppy). I became familiar with the system through trial and error. I asked questions, I did things the wrong way, bore the scolding with chagrin and did it properly the next time. I learned how to brush off the rudeness that you encounter on a sometimes daily basis, grit my teeth through collecting and administering medications (because this is not my job*), learned how to smile the right way to get a porter’s help**, and how often to call the radiology  department to actually get my patient’s goddamn x-ray.

If you ask me (and you are asking me), those are the skills an intern needs to learn and learn quickly. Your medical acumen is already there, you’re already familiar with every procedure they expect of you (it is okay to need supervision; my point is you’ve heard of or seen them all before). What you need to survive is the knowledge of how to navigate the complex social and professional sphere that is the tertiary medical facility. How not to step on toes, when to step on toes, what the unwritten protocols are and how to use them to your advantage (hint: they mostly involve doctors’ egos). I could write a book on helping the fresh faced med school graduate survive, a pocket-sized guidebook probably, but a book nonetheless. Yet here I am, giving it away for free. (I’m tucking this idea away for my first book though. Obviously).

From my viewpoint , having completed almost 75% of my internship I can tell you unequivocally that at some point you will fuck up (the scale of fuck-up varies widely and depends entirely on you). You will feel like you’re the worst, most incompetent intern that ever interned. And then you’ll survive Paediatrics, and you will feel like you can conquer the world. You’ll reach a point where it gets better and you’ll survive this are’t just aphorisms any more, they’re universal truths. You will surprise yourself.

Unless you quit halfway through. And that’s okay too! It’s better to figure out from early that you hate this job and run away to  rob run a bank somewhere. Everyone isn’t for Medicine and this is fine.

The first part is hard, and the middle part, and I think the bit at the end is going to be hard too. Every three months you start over, start learning something else. Carry the good lessons with you, drop the bad habits and keep your wits about you. If all else fails, remember, it’s only twelve more months***.

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* Here I feel obligated to add that helping patients get better is my job. And if that involves getting their medication, mixing it, administering it, wheeling them down to x-ray or up to operating theatre by myself while manually ventilating so their oxygen saturation doesn’t fall below 95% then that is what I have to do.

**Before anyone gets into a feminism/sexism snit I would like to point out that each gender has its advantages in the hospital hierarchy. The guys get nurses and other female staff to do any and everything for their patients just by flexing a bicep. Therefore I am not above using my femininity to get shit done.

***Unless you’re a foreign-trained intern who failed their CAM-C exams. Then you could be here for a long, long time.

Day in the Life of a Paediatric Intern

This post originally titled, Waving the White Flag. (It’s Kleenex).

Where to start with Paediatrics? The current headlining scandal? The mind-numbing, soul-crushing duties? The prickly staff? The demanding work days? How about all of it, all at once, the way it is in real life. Nothing about this rotation happens in an orderly fashion. One time our senior registrar scolded us for not completing discharge summaries on time, saying “they are just as much a priority as dealing with procedures for patients on the ward and from clinic and giving medications”. If it’s one thing Paeds has taught me, it’s that everything can be a priority, all at the same time.

But all this non-stop action has succeeded in murdering my already feeble immune system so that I am now sick. With the flu. Probably. Or tuberculosis. Probably (not). If you know anything about me, it should be that I do not handle illness well. I handle it like a boy, really. Which is probably sexist to say but we all know it’s true. Boys are complete babies when they get sick. And so am I. I curl up in the foetal position and demand soup in a voice that sounds like death colded over*. I am utterly useless at anything involving physical, mental or emotional energy and I sometimes fantasise about using telekinesis instead of getting up to retrieve my phone from the counter five feet away.

Going to work today was entirely out of the question, so I used my leftover energy to feel guilty about calling in sick. I know what a Paediatric work day is like. I also know that I have duty tomorrow and I had to make the decision to take today off so that I could have some reserve of energy with which to survive that 36 hour beat.

This is what a Paediatric work day is like for me:

Starts at 8AM (unlike Surgery which would start at 6:30-7 because the earlier you arrive, the earlier you leave. On paeds you leave late no matter what). At 8AM you see patients on the ward until ward rounds start at about 9:30.

Ward rounds end at about 11AM when you start the day’s procedures which include taking blood, collecting urine samples and sending patients for investigations (like xrays etc). This is for patients admitted on the ward, as well as patients here for the day for a review or patients sent up from clinic.

All intravenous medications are administered by the interns, on a strict schedule. Medication also has to be ordered daily from the pharmacy because they don’t send up more than one day’s supply. This means writing up several charts and getting your senior house officers (SHOs) to sign them because your signatures carry no weight.

Then there is other paperwork like writing discharge summaries and prescriptions for the patients leaving. And there is following up of lab results, mostly cultures from microbiology, that require one of you to go into the lab for about an hour to write down results from the 3-4 books that serve as records.

All this takes you until well into the afternoon and suddenly it’s 3PM and you haven’t stopped for lunch. You just gave the 2PM medication but you can’t eat yet because this baby needs an intravenous access (a ‘drip’) and another baby just got admitted from Accident and Emergency (A&E) needing blood and urine cultures.

There are three of you working but it doesn’t seem like enough. The SHOs will ask “Are you the only one doing procedures? Where’s Dr. So-and-So?” and you will calmly explain that Dr. So-and-So is giving medication while Dr. What’s-Her-Face is in A&E seeing referrals and there’s no one left to help you and they will press their lips together and give you a look which you’re pretty sure does NOT mean “That sounds rough, I’ll help you” and instead means “Well. You’re just gonna have to get your shit together” and you move on with your day. Breathe and move forward should be the mantra of Paediatrics.

After you finish procedures, following up the regular lab results for the samples you took off in the day can take you beyond 4PM because some result always comes back abnormal and needs to be acted on. I don’t like to leave that kind of work on the duty intern because duties are rough enough without adding work that’s carried over from in the day. So I never end up leaving before 6PM and usually leave around 8PM.

I’m not going to get into my eating habits because my aunt reads this blog and would probably have a conniption but suffice to say I would not turn down the offer of a live in chef. Or maid. Or professional masseuse. Or all three in one so I’d only have one monthly fee. Am I setting the bar too high?

Fuck it. The bar was high before I even got here. This whole time I’ve been trying to brush it with my fingers, on tiptoe, stretching furiously toward some untouchable standard. Today I got to rest my aching body/mind/soul for a teensy bit. Tomorrow it’s back to the rack.

Flecti non frangi.

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(*Because death warmed over sounds a little too pleasant. Like Death already got soup and a blankie and now he’s pleased as punch. Although I have been told that my sick voice sounds very sultry so maybe my voice actually is warmed over).

Coming in Live through Your Stethoscope

I like to think my shenanigans on the blog are useful to other people, that it’s not just Jamaican-accented self-gratifying chatter amidst all the other self-gratifying chatter that clogs up the internet. So in the same vein as my posts on medical school and UWI, I’m transitioning into something a little more adult. Still PG-13. Well, depends. Some internship stories are pretty out there.

Mic test.

Internship will probably be the worst year of your medical career. Scratch that. It will be the worst year of your medical career, unless further down the line you end up with a horrible boss who treats you like an incompetent intern. That would probably be worse.

But it’s also supposed to be the most liberal year of your career. The level of responsibility is much higher than medical school (for obvious reasons) but much lower than it will be once you get fully registered as a doctor. Internship is the test the waters year. Dip your toes in all the specialties and a few sub-specialties. See what you like and what you don’t. Free time is limited because you’re first call and therefore can never leave the hospital, but just like med school – doctors work hard and party harder. And sleep even less.

Between the working and the partying (notice how no one cares about the sleeping) it’s important to learn as much as you can. There are aspects of patient management that only become apparent once you start working. Add to your skill set and exposure – minor amputations, sutures, chest tubes, thoracocentesis, paracentesis and neonatal resuscitation (among others) are all the forte of the medical intern. If you show interest, people are almost always willing to teach (because some people are dicks, and there’s nothing you can do about that) and there’s a lot to learn.

While you’re busy learning, take everything with a grain of salt. Always, always be cognizant of the complacency of third world medicine, and the fact that sometimes the things we routinely do are not the internationally acceptable things. Double check your management with evidence-based guidelines (and be up to date), Youtube your procedures to see how it’s being done in more resource-rich centres. Keep your standards high, even if you don’t live up to them.

One inescapable downside to intern year is that people will be mean. People will be mean and cranky and at some points downright bitchy. They will take their frustrations out on you; you will end up being blamed for the incompetence (and sometimes sheer slacking off) of other people. Patients will yell and cuss. Staff will grumble and talk about you behind your back. Work environments (as I have discovered) are rarely if ever rose gardens. And even if it smells pretty, there are usually thorns.

So, keep the faith. Remember why you started doing medicine in the first place. If that doesn’t work, remember that you won’t be at the bottom of the food chain forever. If that doesn’t work, remember that at least you have a job that pays more than most in this country. And even though sometimes I feel the urge to be just as mean back to them, I have found time and time again that it pays to be nice (even if you have to fake it til you make it). Also that having friends in every department is pretty much the only way to get things done for your patients in an overwhelmed, understaffed system (as I have mentioned before).

 In my last seven months, I’ve developed some words to live by to help me keep my sanity.

Don’t be a hero, is what I learnt from Paediatrics.

Surgery taught me that responsibility is informing your seniors.

And on Internal Medicine, I am learning that you catch more flies with honey than with vinegar.

Somewhere in these ramblings, I hope you find a truth you can apply to your own internship. Or maybe it’s enough to know you’re not in the struggle alone.

All of Only Halfway There

What’s the hardest thing you’ve ever had to do? Physically, emotionally or mentally. Have you ever stretched yourself to the absolute limit?

What did you find? Did you break, or just bend? Did they crush you?

I bet you survived. Humans are like that. Determined as cockroaches.

My Paediatric experience will be unlike any of my batch-mates. We manned the special care nursery at a time of national crisis – babies were dying, health ministers were being impeached, the public was furious. We interns, the most junior staff, were the bulk of the paediatric department. To say we were screwed was an understatement. Every odd was stacked against us.

And yet.

We survived. Not just survived, thrived.

Of course, the first six weeks were the worst hell imaginable. I cried at work. Twice. I pushed IV medication and the lab staff and myself. I lost weight, I was anxious all the time. We all had chronic fatigue.

Then slowly and painfully, like a lizard shedding its skin (does that hurt? I feel like it should hurt), we metamorphosed, Kafka-style. Almost overnight we hardened, gained competence. The odds were still stacked, but we got better at playing them. The workload lightened. For doctors who were molded by an overpopulated nursery (thirty babies our first few weeks), taking care of eight newborns (plus or minus three) was child’s play. I moved from the desperate panic of ‘How will I survive this?!’ to the weary surprise of ‘I must have been stronger than I thought’.

Like all things do, my three months on Paediatric Medicine passed. January 4 I stumbled into the staff meeting bleary eyed and battle-worn but ready to take on whatever staff assignment they threw at me. Internal medicine was my new playing field. Game face, on.