Making It All Worthwhile
So it turns out that learning medicine takes quite a lot of work. Already many of my friends are having second thoughts about doing this for the rest of their lives. Do we really want to commit ourselves to lifetimes of exhaustion and frustration with little or no free time? Can we honestly make ourselves believe that the job of a doctor is that worthwhile?
Oh yes. Because then we can do things like
this.
Fantastic.
As it happens, this is the kind of thing we medical students discuss on a regular basis. What would be the best way to throw away your career and go out in a blaze of glory? Get caught in a sexual harassment scandal? Pull a Shipman? Spend evenings switching babies in the neonatology unit? It's alarming how often we put serious thought into how to screw things up from within the system.
Return of the Medi
Today was my first day in clinical school. I don't quite have that new school feeling, partly because I already know a few people here but mostly due to us all being dressed up like (terrified-looking) junior doctors. Judging by my schedule for the next fortnight, I’ll be too busy to let the change of location really sink in for a while. We have training all day and social activities scheduled all night to ease us into a state of confused and drunken acceptance of our new lives..
I find I’ve enjoyed beginning each stage of my academic career more than the previous one because each time I’m surrounded by more and more enthusiastic people. By A-level, I was already sharing most of my school time with students who had specifically chosen the subjects in which they had particular interest. This was even truer of my undergraduate university education and is absolutely key now. Everyone who is here is here because they want to be. They’ve worked damn hard to be here. They all appreciate that, and that makes for a phenomenal group spirit even on the first day. Freshers’ week three years ago was an irritating period of false friendliness and mass insecurity. I get the feeling that this one will be wholly more enjoyable.
Most of the day was spent by basic administrative fumbling around; dishing out new white coats, selling stethoscopes to those who need them, demonstrating how to use these newfangled personal computing machines that let us access interspace, etc. We were given a rather double-edged lecture to reassure us that if we start to suffer from any sort of mental disturbance the medical school will be entirely supportive, but we really do have to tell them as soon as we become aware of it. Statistically, many of us will become depressed. Or substance abusers.
In one welcoming lecture, the speaker went through great lengths to point out that the university actively pursues a policy of “non-humiliatory teaching”. He then apologised that this couldn’t always be reliably enforced on the wards. This is about as comforting as being told by your airline pilot that he has a policy of trying not to plummet to the ground in a ball of fire.
The highlight of the day was our first clinical lecture, in which we were taught the basics of taking a patient history. The lecturer rounded off by introducing us to a real live patient who has just arrived back from Australia and has been having a pain in his leg since he got off the long-haul flight. The patient, a man in his mid-twenties wearing surgical stockings, is wheeled on and nervously answers a few questions. He is apparently stable and under close observation by the hospital staff as well as the couple of hundred shiny new medical students in the lecture theatre.
The lecturer randomly picks three of these students to come up on stage and cobble together a history. Between the three of them, they seem to manage a decent job, shambling through the main aspects of his past medical and social history and ticking off Socrates in a roundabout fashion. The lecturer then invites one of the students to give the patient’s leg a cursory physical examination, something of which she has absolutely no prior experience.
The student obliges and, when lightly rebuked for being too gentle, lifts up the offending (offended?) leg and gives it a squeeze. Naturally enough, the patient gives a cry of pain and the student backs off in terror. But the pain doesn’t seem to go away and the patient clutches angrily at his leg with both hands while the student mumbles her apologies. The patient isn’t listening. Instead, he’s clutching his chest and falling to the floor. The lecturer takes control of the situation, bustling the students out of his way (something I understand doctors are forced to do on a regular basis) and shouting, “We need a crash team in here – stat!”
We are, after all, in a hospital.
Within seconds a pair of figures in blue scrubs run onto the stage of the lecture theatre and begin trying to resuscitate the poor patient in front of an aghast audience. After ten or twenty seconds, one of the emergency team cries, “We need more people in here!”
About twenty more medics in scrubs run onto the stage. Music starts playing over the speakers. It’s Queen’s Another One Bites the Dust. The bescrubbed medic dance in formation to the music. The patient lies dead on the stage. Jaws slowly lift off desks around the lecture theatre as we realise that this elaborate prank was arranged purely to advertise a medical school charity event later in the term. This place rocks.
Right now I’m heading off for some substance abuse, no doubt followed by ritualised humiliation.
Back in the Saddle
Yesterday I arrived home from holiday to find that I had somehow screwed up the publishing process for my last post, meaning that it never made it onto the internet. The gist of the post was: “I won’t be posting for a while because I’m going on holiday. Check back in September.”
Now that my admittedly limited readership has dwindled away to nothing, I’m ready to continue the reportage of my ongoing medical education. Oddly enough, I actually find it much easier to gather the motivation to write during the term time than during holidays. Being forced into a schedule somehow makes me more productive in areas that are completely unscheduled. I suppose that I’m forced to manage my spare time more efficiently. This is just as well, as my spare time is about to become a scarce commodity.
Term starts for me on Monday. Better yet, clinical school starts for me on Monday. In fact, a completely different university starts for me on Monday. That’s right, people - update your bookmarks, because I’m no longer an Oxford student. I’m going to the big city. Well, a bigger city, anyway.
In the interests of the anonymity of my future patients, however, I am choosing not to disclose the precise location of my impending studies. I expect that from time to time I will write in this blog about medical cases I see and, while I will go through every effort to protect patients’ identities (details will be changed, names will be fabricated, amusing Scandinavian accents will be added), I do not wish to risk jeopardising either their privacy or my own. Please do not ask me to reveal my location and, should you infer it from my writing or by more dastardly means, please do not pass it on to others. Thank you.
Why did I leave Oxford? Simply put, I wanted a change. A medical degree (technically two degrees) takes six years. In practice, this often turns into eight years as most people stay in the same place for their foundation years of actual doctorhood. Oxford is a beautiful city and has a lot to offer in terms of entertainment, culture and amenities, but I still wanted a change. I will miss it.
Many of my friends have just graduated or will be graduating next year and their post-university diaspora will mean that my geographical location will become less relevant to maintaining contact. Wherever I end up living, my friends will be spread around the country and, in some cases, the rest of the world. Now, far more so than when I left school, I honestly feel that I will stay in touch with the people with whom I wish to stay in touch, regardless of distance. Nobody I know is ever more than an email away and it will only be a couple of years before affordable teleportation devices hit the consumer market.
I’m eagerly waiting for Monday. A glance at my timetable tells me that within the first two days I’ll be getting down to the sort of hands-on clinical work that I’ve merely fantasised about for the past three years. I’ve enjoyed being a scientist, but next week I have to start learning how to be a clinician.
Wish me luck.
A War Is Coming
I’m back. I’ve been away. Sorry for not telling you. No, I didn’t get appendicitis again. Many thanks to the kind people who sent me get-well-soon cards anyway. I don’t know how you got my address and I’m thoroughly spooked. The chocolates were delicious.
I’d like to tell you a couple of stories. Bear with me here, I’m trying to make a rather heavy-handed point.
Story One: I have a bad feeling about this…
Once upon a time there existed an Order of mystical individuals dedicated to the protection of society from dark forces. Members of this Order, which approached a sect in its quasi-religious nature, commanded much respect from outsiders and were regarded as belonging to the societal elite.
Not just anyone could join this Order, for its members were notoriously selective in choosing their acolytes. Novices were chosen on criteria that seemed unclear to the public as well as to many of those who had already been ordained. A high degree of intelligence and willingness to follow the Order’s principles were basic requirements, but from among the pool of seemingly suitable candidates only those deemed to possess an innate aptitude for the Order’s magic were allowed to progress to training.
The training itself was arduous and extensive, with many falling by the wayside. However, those who completed the training, if such a training can ever said to be complete, found themselves imbued with powers beyond the imagining of mere mortals. A precondition for wielding such power was that members swore an oath of allegiance to their society and to the Order, promising to only practise their arts for good, never for evil. And so the society welcomed these learned individuals and came to rely on them as the first line of defence against all manner of threats to the peace, from invading armies to internal civil strife.
Eventually, the highest rulers of society grew wary of the Order; it had little accountability for its actions and often seemed to demand more than was reasonable in exchange for protection which was frequently less than tangible. The rulers even went as far as to consider abolishing the Order entirely, but knew that to do so would be impossible. The public held the Order in highest esteem and would view such a radical suggestion as an incitement to revolution.
The newly established emperor hatched a more diabolical scheme. It just so happened that a powerful evil was threatening the society in question and there was much public concern that the benevolent Order would not be able to fend off this evil. Already it was clear that the members of the Order were stretched to the limits of their endurance in keeping the evil at bay. The emperor proposed a solution that pleased the public greatly.
A new army was conjured to assist the Order. This army consisted of vast numbers of near-mindless drones, each individually incapable of original thought, but excellent at following orders. The drones were taught to fight alongside the Order, ostensibly working towards the same goal: protecting the society. Led by the elite warriors of the Order, the new army seemed an unstoppable force and many wondered why the Order had not proposed it before. There was much speculation that the mystics of the Order would have preferred to keep the power for themselves. Despite a few sceptics, most member of the Order were welcome for the assistance and made full use of the increase in manpower to continue to repel the invading evil.
Then, once the Order had fully accepted the presence of the new army, the emperor used the drones to wrest power away from the Order. The previous defenders of the realm found themselves attacked from within but continued to fight valiantly for the safety of the society, even in the face of this betrayal. As their oath dictated, their first duty was to protect their people, not to preserve themselves against political machinations. The Order dwindled to a few noble members, left disparate and ineffectual, surrounded by an unthinking army that was obedient only to the emperor.
Of course, in the absence of the Order, the original evil was able to thrive and threatened to consume the society unopposed. A new era of human suffering and societal collapse was heralded. The emperor was unconcerned by this, having accomplished his own ambitions, so the fate of the people was left in the hands of the scattered remaining members of the original Order; only they had the potential to expel the evil from the land and restore the society to its former prosperity. The odds were very much against them succeeding.
Story Two: The weavers who failed to cotton on
This tale concerns a village of weavers. Almost all of village’s inhabitants made their livings by weaving fine garments for trade in the larger towns and their skill was such that any garments they made were always in high demand. Generations of experience went into each piece of clothing, so the name of the village became synonymous with fine quality apparel.
The weavers were also highly versatile; they were always able to adapt their craft to match the latest fashions and if any specialist orders were received – for designing exotic costumes or using the most unlikely materials, such as gold or even tree bark – someone could always be found who was up to the challenge.
One day a traveller passed through the village, paying his way with expertly told and consistently implausible stories of his own adventures in their own country and abroad. A crowd quickly formed in the tavern, laughing along with his accounts of giant grey cows with flexible noses the length of their own bodies and listening in rapt silence to his description of the sudden naval battle that had nearly sunk his own small raft. But nearly every weaver in the tavern scoffed and jeered when the traveller casually mentioned a place where cloth would weave itself. The only exception was a restless young fellow who, having been intrigued by the traveller’s tale, set off the very next morning with the resolution to find this cloth that wove itself.
A year later, to the very day, the young man returned to the village. He looked ragged and half-starved but was riding a clapped-out cart, pulled by an equally clapped-out mule. He grinningly explained that the cart contained a device that he had bought at much cost, a device that was able to complete a weaver’s day’s work in a matter of minutes. To the astonishment of the gathered mob, the young man activated the device, which began churning out yards of very coarse but serviceable material.
The village was instantly divided into two factions. The majority of the weavers believed that the new device was nothing more than a novelty, since it was unable to produce material of any quality. A few, however, saw it as a source of great potential and went about studying the machine to find out how it worked and what modifications could be made to improve its function. Within a few months, these weaver-cum-engineers had built a number of different machines, capable of producing finer materials and even whole garments. Each machine still carried the limitation that it could only ever produce one very specific product, but at a rate much faster than that of the most practised artisan.
The machines quickly gained popularity with the youths of the village, who, unlike the elders, did not regard them as akin to heresy. Machine-produced clothing became all the rage and output soared, driving many traditional weavers out of business or forcing them to start designing and maintaining their own weaving machines. The machines gradually but continually improved in the quality of material they could produce. The elder weavers continued to object to the machines, saying that they lacked the versatility and personal attention that was really required in the weaving business. The general public, however, did not seem to care and were thrilled by the cheapness and availability of so many clothes. By this point, there were so many different clothes-machines running that it did not matter that any one of them lacked for versatility; taken together, the machines had a far larger repertoire than any one weaver, so there was plenty of variety from which to choose.
One or two of the traditional weavers managed to eke out a living by appealing to the increasingly specialist markets for which machines were unsuitable. Within a generation, everyone had come to accept that it was easier, faster and cheaper to produce clothes by machine than by hand and the quality was as high as it had ever been. The village thrived and most of its inhabitants were appalled by the idea of clothes ever having been made by hand. They shuddered at the thought of the long hours their ancestors had invested for such little reward and thought it absurd that once each weaver had been required to learn how to produce so many different types of clothing. Both the producers and the purchasers of clothing agreed that the new way was much better.
What I was getting at
You will no doubt recognise Story One as the plot of Star Wars Episodes II and III. It is also, I suspect, how some British doctors have come to regard their own plight. They see themselves as the noble Jedi being betrayed by their government’s creation of a clone army of nurse practitioners.
They fear that their own training and expertise will be replaced by an easily funded workforce with very limited capabilities. The autonomy that would let a healthcare system run smoothly is prevented by the political ambitions of those such as Sith Lord Blair. The Medi-Jedi object to having to justify their existence in terms of artificially constructed government targets when they could be focussing on defending their people from the evil threat of disease. They think that doctors are better at fighting illness than nurses are. The media accuse them of professional snobbery and elitism when in fact they trying to act for the good of the nation. The trust that the public once placed in them has vanished but they fight on regardless. They worry that they are fighting a losing battle and that soon the fate of the galaxy will rest in the hands of countless dedicated but undertrained specialist nurses. The people will pay the price.
The government would probably prefer Story Two, the fairy tale industrial revolution. They view many doctors as old-fashioned weavers who are too stubborn to realise that the way they practise their craft has become outdated. Nurse practitioners are the machines that will make medicine more efficient and able to meet the demands of our huge and sickly population. It is unreasonable to expect doctors to shoulder the responsibility alone; why have a small number of doctors trained to deal with hundreds of diseases when we could have a large number of nurses, each capable of dealing very efficiently with a few diseases? As long as a system is in place for the right customer/patient to access the right machine/nurse, business will run smoothly, cheaply and without a loss of quality. Of course, doctors would not be done away with entirely. They are still needed for research, training and to deal with the specialist cases that really do require their extensive training.
It is only natural that doctors would feel threatened by these radical reforms. It also natural that the new system would encounter teething problems and that the first generation of machines might have a few flaws in their design. Given time, though, a healthcare system based on this kind of parallel processing should prove beneficial for all involved, particularly the public.
Qualifying that
I realise that these are two extreme caricatures of the sides of the nurse practitioner debate and that both are based around the assumption that nurse practitioners will, to some extent, replace doctors. I also realise that both stories here come off as quite insulting to nurse practitioners, presenting them as unthinking beings compared to the highly skilled doctors. It’s a caricature. The point was to illustrate differing views of the increasing compartmentalisation of medicine and medical training rather than to reveal profound truths about the individuals involved.
Where do I stand? Are doctors the hard-done-by Jedi or the outmoded weavers who overvalue their own worth? Do I follow Qui-Gon Crippen or Darth Hewitt? I still have no experience of our healthcare system from the inside. I have never talked to a nurse practitioner. My only knowledge of the matter is second hand, from news articles and blogs. I would instinctively prefer to believe the first viewpoint, if only because it is flattering to my ego. And I secretly want to be a Jedi. I am taught by doctors and am planning to be a doctor, but that does not to equate to believing that doctors are infallible or that they are irreplaceable.
Once I see how doctors are actually being treated within our healthcare system, I’ll get back to you. For now I cannot reasonably say whether they’re being screwed over like the Jedi or are just moaning about the next generation having it easier.
Contaminated Gene Pool
Today I came across an article on the BBC website about Robert Klark Graham’s controversial repository of genius sperm. In case you haven’t heard of this project, it was a wealthy eugenicist’s scheme to breed Wunderkinder by using only the finest sperm, hand-produced by the intellectual elite of the 1980s and 1990s, implanted only into the ova of the married and affluent.
What drew my attention was the list of comments at the end of the article. I was expecting the usual range of indignant comments about millionaires/scientists/Americans trying to play God, with perhaps one or two people sticking up for the pariah. Surprisingly, not a single comment had been posted (at the time of my reading) that disapproved of Graham’s project. Evidently the BBC readership is content to accept favourable genetic constitutions as marketable commodities.
What surprised me more was that one reader had written:
"In Britain most sperm is donated by students, especially medical students, so in all probability your "donor" is going to be much brighter than average anyway.”
This was news to me. I cannot say that I had previously put much thought into the exact provenance of banked sperm, but I can see how it might draw students. It’s money for tugging old rope. And I suppose that medical students would be more likely than other flavours of student to consider selling their sperm because (a) they’re used to handling their own bodily fluids, (b) they hang around the kind of places where fertility clinics are advertised, (c) they have a pragmatic approach to recombining genetic material and (d) they have six years of student debt to pay off. Also, they tend to be a bit weird. I can understand how they might have come to be the stereotype of impoverished sperm donors, but is there any truth to the cliché?
As it turns out, no. Despite casual assertions on various web pages, including another BBC article, that most sperm donors are students (particularly medical), the Human Fertilisation and Embryology Authority maintain that today most donors are aged over 30, with the most common age band being 36-40. However, eleven years ago nearly 70% of donors were under 30, with those aged 18-24 being the most seminally generous. The HFEA website does not give a profile of the donors according to profession, so I cannot say how many of them were medical students.
However, I like to think that there are a disproportionate number of ten-year-olds running around today with unusual predispositions towards autopsying their dolls and palpating their playmates. These will be the doctors of 2020. When I meet them, I’ll wonder why they remind me so much of the doctors in their thirties who taught me in medical school.
The Supersonic Cardiac Reflectoscope
Not a day after my last post, a notice appears in the medical faculty building announcing an anatomical drawing competition. I have chosen to take it as a sign, so am in the process of cobbling together an entry.
There is quite a variety in the standard of teaching we get from our prosectors at the moment. At the lower end of the spectrum are the ones who do not know any more than we do, but try to cover this up with increased class participation and awkwardly phrased rhetorical questions. Now into their second week of teaching third-years, they seem fairly apathetic about whether we realise how little they know. This is an improvement, as rather than try to bluff their way out of a difficult question they now openly refer to textbooks or ask other prosectors. I hope that we have not broken their spirits entirely; this can be a learning experience for them as well as us. On the plus side, I am inclined to think, “If they can become doctors, anyone can.”
The prize for the best prosector so far goes to a Welsh chap who, while not necessarily the most knowledgeable, certainly shows the most dedication to the cause. This afternoon he gave himself a nosebleed in an effort to demonstrate the vasculature of the face. Far beyond the call of duty.
I spent today’s CAL sessions reading about the curious life of Lazzaro Spallanzani, the eighteenth century priest, teacher and experimental physiologist. Crackpot that he was, he suggested that bats might be able to see using their ears rather than eyes. The preposterous notion of sounds existing above the frequency of human hearing was widely ridiculed until Spallanzani published the results of some imaginative experiments using blindfolded bats. Despite these efforts, many scientists remained sceptical. As it was, humans were unable to make use of ultrasound as an imaging technique until the development of piezo-electric crystals nearly a century later. The first underwater echo-sounding device was patented in 1914 and by the 1950s “supersonic reflectoscopes” were being used to look inside closed objects of both the inorganic and the organic kind. I think it's a crying shame that we call it echocardiography today.
At first I found the idea of blindfolding bats for physiology experiments hilarious, but then it occurred to me that I have actually worked for many months in a lab that specialises in making ferrets wear different kinds of headphones to see how they localise sounds. Suddenly blindfolded bats did not seem so farfetched. However, I still think it a great shame that I have missed the era of science in which one might decide on a whim to investigate bat hearing one day and human reproduction the next. Research these days takes years to build up momentum, so we rarely see the Da Vincis, Newtons or Spallanzanis who once seemed to churn out a revolutionary discovery every other Tuesday. I know there are many good reasons for this - modern science has become incomprehensibly vast as well as minutely detailed and is no longer purely the domain of the privileged and gifted – but I cannot help feeling that science was more of an adventure in the olden days.
I take comfort from the fact that doctors and particularly physiologists still have a cavalier approach towards conducting experiments on themselves and their colleagues, whether they are paralysing each other for dyspnoea research, vaporising the blood in their own hands to simulate sudden spaceflight decompression or climbing frozen mountains just to see how the body copes. As it happens, I have met researchers who have done all of these things and lived to tell the tale. Even if research today has to exist in a culture of continuous self-justification and fund-grabbing, medical researchers are still able to have fun while they do it.
It's What's on the Inside that Counts
I’ve been studying the musculature of the face and hand, so I thought I’d upload this self-portrait. If you recognise me in the street, do feel free to say hello. You should probably also call me an ambulance.
The exam on Friday afternoon went well and by Friday evening I had received an email to inform me that I had passed. Just one of the joys of automated multiple choice question marking. I can now forget everything I’ve learnt about the musculoskeletal system for at least another two months. The beauty of being examined at the end of each week of this three-week anatomy course is that (a) we are not expected to spend weeks preparing for the exams and (b) we only have to hold information in our brains for a maximum of four and a half days at a time. Yes, this is an irresponsible attitude. No, I’m not bothered by it. At this time I cannot realistically be expected to commit to long-term memory the majority of what I’m being taught. I think I will remember the important parts, but I won’t be too upset if I forget the precise origins and insertions of some of the muscles of mastication.
A comment about my last post has got me thinking about just how much we are expected to remember. I’ve heard clinical students casually remark that once you get to clinical school you can forget everything you’ve learnt in the previous three years. They exaggerate, but I wonder how long the medical course really needs to be. What is it that we pick up in five or six years that we couldn’t pick up in three or four? I’m inclined to think that the important aspect of our training is not the facts that we learn, but the way we learn to think. Surely the longer we immerse ourselves in our field before we’re unleashed on patients, the better. Our minds are slowly shaped by our own familiarity with the subject until we transcend into doctordom. Some countries insist on even longer training periods; what are we missing that their students are getting? Are we better or worse doctors for it? Answers on a postcard to the usual address.
This week I’ll be learning about the cardiovascular and respiratory system, in both of which I specialised for my third year. This doesn’t mean that I know much fine detail about their anatomy, but I’ve got a reasonable idea of how they work. Air goes in, air comes out. Blood stays in (ideally) and goes round and round. As long as I manage not to mix up those two, I should be fine. I’m a big fan of any organ system that can essentially be reduced to plumbing or, as with peripheral neurology, wiring. I can appreciate endocrinology and immunology, but they are nowhere near as instantly tangible and intuitive as the bits of the body that are made up of tubes and pipes. If I ever drop out of medicine (or if I’m ever struck off), perhaps I’ll take an engineering degree.
