Life in the Emergency Lane

Capture

This talk was brought to you as part of the biannual When I Grew Up series hosted by the Australian National University Medical Student Society. Our guest speaker is Professor Caldicott, who is an Emergency Department Consultant at the Calvary Hospital ACT. It is one of the most heartfelt and genuine talks that we believe all medical students and junior doctors should hear. There are so many pearls of wisdom about living and surviving as a doctor that we can all learn from. This is a raw, honest and entertaining reflection from a senior clinician practicing in one of the most challenging and exciting fields in medicine.

Our Guest Speakers Bio

Professor David Caldicott who is an Emergency Consultant at the Calvary Hospital and a Clinical Senior Lecturer in the Faculty of Medicine at the ANU. He is a spokesperson for the Australian Science Media Centre on issues of illicit drug use and the medical response to terrorism and disasters.

Professor Caldicott designed and piloted the Welsh Emergency Department Investigation of Novel Substances (WEDINOS) project in the UK, a unique program using regional emergency departments as sentinel monitoring hubs for the emergence and spread of novel illicit products. He is currently replicating this work in Australia with the ACT Investigation of Novel Substances (ACTINOS) Group.

We’re now on YouTube!

We’ve expanded…into YouTube! (http://bit.ly/CommonRound)

Check out our Channel!

Check out our Channel!

This opens up a whole world of opportunities for us to SHOW you the things we talk about. Anatomical structures, pathology pictures and many more awesome things we can think of!
Subscribe to the channel to not miss an update.

For now, enjoy our first video on how to draw the cranial nerve nuclei in the brainstem.

Rural and Indigenous Healthcare

As a young health professional, I have practiced and worked in a diverse range of settings and have had the opportunity to experience a variety of roles prior to entering medical school. I’ve come to ponder upon the future of healthcare in Australia and the current trajectory and circumstances. Whilst, I acknowledge that my view is not conclusive and am not attempting reprimand or critique rather to highlight the issues that are explicitly evident in the healthcare system.

My first concern relates to the state of rural and indigenous healthcare. I have worked within the hospital setting both in Central Australia and rural South Australia. Indigenous health is a passion of mine and we are all well aware of the challenges faced by practitioners intent on closing the gap. Rural healthcare, of which indigenous health is an integral component is faced with enormous obstacles. There is an evident lack of resources and facilities that creates difficulties in delivering optimal care to patients.

Furthermore, it is a challenge to recruit and retain health professionals to stay long-term and to help address these health disparities, thereby creating long waiting periods that progress and complicate health status of patients. Moreover, the vastness of this magnificent continent generates logistical challenges in delivering care. Patients often travel long distances or may not have access to transport to seek help.

Of indigenous health so much requires attention. Most obviously the communication and cultural barriers that impede and disconnect the patients from their health professionals. In addition the social factors that create a revolving door approach to healthcare. Factors such as inadequate accommodation, nutrition, employment and education are essential to maintaining good health. What of the cultural unpreparedness of health professionals dealing with indigenous patients? How can we integrate contemporary medicine with indigenous health concepts and spirituality? Hope is not lost, mainstream Australia is awaken to the ever widening health disparities…

Another major issue is the ageing population of Australia. This dilemma is confronted by many other countries and is not unique to Australia. Advances in medicine have led to improvements in quality of life and increased life expectancy of patients. The ageing population will be placing enormous demands on resources, trained staff and healthcare accessibility. The issues are complicated by an ever-growing list of new and costly therapeutics that place further pressure on finite resources. Is the current healthcare system prepared for the future? Are patients and health professionals positioned to accept the limitations of the current model and finite resources?

Related to the previous paragraph is the growth of chronic and lifestyle diseases that are becoming more prevalent in younger adults and children. We are faced with a growing epidemic of obesity, diabetes and Cardiovascular disease. These iIllnesses were absent in or less prevalent in previous generations of similar age group. This places further pressure on resources and management of complications associated with these conditions. Nevertheless, hope is not lost and positive steps in the right direction are being taken….More on that in my next update.

Interview Techniques

I mentioned before preparing for medical school interviews is really important. Don’t listen to people who advise otherwise. Leading up to the interviews I was practising on a nightly basis with whoever was willing to put up with me!

When you practice you need to develop techniques to ensure that you tackle interview questions efficiently and comprehensively, whilst avoiding the risk of sounding rehearsed. Sounding rehearsed is less likely to occur for MMI style universities but can be a major issue with traditional panel interviews. However, with the following strategy I found it reduced the risk of sounding rehearsed for any interview style.  

  • Situation – describe the situation or the context that you had found yourself.
  • Task – What were your tasks  that you had to tackle in the scenario that you have outlined
  • Activity – How did you go about achieving the tasks that you set out for yourself
  • Result – What were the outcomes of your activities. Did you adequately resolve the scenario if not why? What did you learn from the experience.

As you can see using this approach enables much greater focus and structure whilst reducing the risk sounding rehearsed. I’ve found that I was able to address many questions that were asked during the interview. The structure also ensure that your answers are clear and succinct (so you don’t waste time babbling on).

There is also an approach that you can employ the tackle the ethical scenarios that may be asked. The approaches is inspired by the Hippocratic Oath.

Consider these scenarios with the following ethical frameworks:

  • Justice: any approach you propose to tackle the ethical scenarios must be ensure that it fits within the law (so long as the law is within reason e.g killing a population because it is enshrined in the law is not an adequate excuse for the action – refer to the Nuremberg Trials and Nazi experimentation)
  • Autonomy: refers to respecting the patient’s right to choose the course of their life without external interference, e.g you can’t normally a force a treatment onto a patient.
  • Beneficence: you’re actions should be of benefit to the patient and or the individuals involved in the scenario
  • Non-Maleficence: do no harm (pretty self explanatory)  

If you get issues relating to consent or a scenario trying to explore your understanding consent you can approach this by considering the following points:

  • Informed: does the patient or person understand the information you are providing them?
  • Capacity: does the patient or person have the capacity to comprehend the information you are providing them? For example is a child able to provide informed consent (read more about Gallick Competency).
  • Free from duress: did the patient/person consent under their own volition or were they influenced by family/friends.

What are Objective Structured Clinical Exams?

Before entering medical school, I had heard the term OSCE mentioned/referred to a number of times. I read a little about OSCEs but I had very little appreciation about what this type of examination is and how it is applied throughout the medical school examination process. Having now worked my through OSCE-like assessments, I would like to take this opportunity to discuss this examination technique for premed students who are curious about it. My impression is based on the ANU medical school assessments but I think the overall principles apply to most medical schools.

Throughout medical school you are being taught a wide range of clinicals skills, which are highly practical in nature. They are the fundamental skills that are used for examining/interacting with patients. These practical skills are different to the what is taught within practical classes (refer to practicals in medical school guide for an overview). Just like other aspects of the curricula it is important to assess students in the knowledge and application of these practical skills. The clinical skills can encompass discussing patient blood and biochemistry results to perform procedures/physical exams.

At the ANU medical school, a day is set aside to examine all students in the year level on these clinical skills. Students are divided into groups who are assessed over an hour. We have no idea what clinical skills will be examined on the day. However, throughout the semester you develop an appreciation for the key skills that are likely to be assessed in these exams (but you can always be surprised!). The exams start with students being taken to the clinical skills rooms. You are provided with a scenario outside (e.g a patient presents with chest pain, patient has noticed a lump, patient is complaining of a sore tummy in ED etc…). You read the scenario(s) that are provided with a minute or two to think about how to tackle the case.

You are then called into the room but before you can proceed with the clinical examination you will need to introduce yourself to the camera, which records your entire exam. The purpose of this is to ensure that you are in fact who you say you are and also the camera recording can help resolve any disputes about the marking of the examination. After completing this formal step the examiner may ask of you to perform the clinical skills (e.g cardioresp assessment) on the actor (or patient). You then introduce yourself to the patient, obtain consent for the procedure and begin the clinical examination. You have to be very efficient as you are under time pressure to perform the clinical exams. In each room you will be required to perform up to two exams or an exam and a viva (where you discuss a particular investigation or clinical scenario). Once your time is up you may need to sit down with the examiner to discuss your findings.

Otherwise you will be asked to leave the examination room in preparation for your next station. Usually in the adjacent room. You will be then asked to come into the next examination room to continue with the next set of clinical exams. So as you can see OSCEs are an efficient means of assessing a number of clinical skills within a relatively short period of time. These skills are important for your competency in the clinical years and beyond. Moreover, it is a tool by which the university can ensure that you are remaining up to date with the extensive range of clinical skills taught. I hope this article sheds a bit more clarity about OSCEs. Feel free to leave a comment or get in contact with us for further clarification.

What is it like to study medicine?

I am often approached by medical student hopefuls about the study requirements of medicine. They often ask about the workload, the stress of study pressures and managing work/extracurricular activities whilst studying medicine. Choosing to study medicine and the life of a doctor is not for the faint hearted. You will need to have love for learning, continuously improving and being challenged at every step of your career if you decide to embark on this journey. Medicine is not a job it is a vocation. It doesn’t end when your working day finishes. Nor does it end when you are on breaks from university and on weekends. Before you start medicine you will need to acknowledge these aforementioned points and weigh that with the type of lifestyle you wish to have while you study medicine and practice as a doctor.

So what is an average day like for me (note everyone has a different routine)? I tend to get up early in the morning have breakfast and head to university around 7:30 to 8 am. University lectures typically start at 9 am (although clinical/hospital days tend to start a little bit earlier). I utilise the time before the start of university day to read and catch up on lecture notes. I tend to do a bit of pre-reading before lectures as it helps with my understanding of content covered in lectures.  During lectures I tend to take notes on the slides to make sure that I accurately document the points raised that were not contained within lecture notes.

For every lecture where appropriate I tend to do a quick summary of the lectures guided by the lecture objectives. ANU provides lecture objectives which are essentially key topics that are potentially assessed during exams. Moreover, they help focus your learning as studying medicine is a big task and you will need to focus on high yield areas. When studying medicine you will also need to acknowledge that you will not be able to learn and become an expert on every topic. There are simply too many lectures, covering a broad range of topics. Consequently, I’ve had to personally accept that I will not be a master of every topic and acknowledge that there will be gaps that will need to fill as I progress through medical school and beyond. Its an uncomfortable feeling but also very humbling as it will reflect real-life medical practice. The key is to actively recognise your ignorance and avoid guessing and making inappropriate therapeutic decisions.

Medicine at ANU tends to be 9 am to 5 pm most days of the week (excluding the weekends). For the first two years you are the university campus and for the last two years you are the hospital or undertaking placements in the community. The working hour could vary significantly depending on the rotations. I know students who have worked 12-15 hour shifts in a surgical/Emergency medicine rotation.

In the evenings I tend to relax for a little bit or go to the gym and exercise. After dinner, rest and catching up with my partner I start studying which could involve  a few hours of reading, taking notes, working on assignments. I tend to spend at least 2-4 hours per night studying and keeping uptodate with lectures, pracs and clinical skills. I aim to head to bed by 11:30 pm to 12:30 am. Sometimes you do lose a bit of sleep but I encourage everyone to try to get a decent amount. It is fundamental for memory, mood and alertness throughout the day. Getting an adequate amount of sleep is something that I constantly struggle with, particularly during exams.

My routine on weekends involves usually having Saturday morning off to go out and play sports or spend time with my family and friends. Its something that I look forward and helps bring a bit of balance into my life. Depending how busy the university week has I tend to start studying after lunch and continue into the evening. If I feel I have adequately caught up on my work then I aim to have sometime off in the evening to relax with my friends or family. On Sundays I work throughout the day and study in the evening to catch up on work remaining from Saturday or preparing for the week ahead and pre-reading/revising for the week ahead. I feel that with a bit of pre-reading and preparation I can better maximise my learning during the week. But I know everyone has a different routine and I definitely advise you to experiment and explore what works best for you.

Research Projects in Medical School

As a medical student and all throughout our medical careers there is a strong emphasis on evidence-based practice. It underpins modern medical practice and informs the best approach to patient care and treatments. It is not surprising that medical schools place a strong emphasis on understanding and appreciating evidence-based practice. This is highlighted by population health courses and research projects. At the Australian National University, we undertake a major research project which roughly equates to 12 months. The project runs concurrently to our usual course load.

The aim of the research project is to give an insight into research practice as a clinician. Most doctors we will ultimately be involved with some degree of research, whether it is a clinical audit or supervision of students. We are provided with an opportunity to explore research interests in a diverse range of medical specialities. The type of research is also very flexible, although the choice of my project must be realistic. For example students are discouraged from participating in randomised clinical trials as they could potentially go for greater 12 months and there is a risk of not completing this assessment project within the allocated time. Many students chose to undertake clinical audits of various shapes/forms. Others prefer laboratory-based projects. Some students are undertaking interviews, surveys and even systematic reviews! So the possibilities are endless.

The projects are a fantastic way to develop further practical research skills ranging from data collection to data analysis. It is a wonderful opportunity to learn and apply various statistical methodologies and many students utilise softwares for this purpose. Over the course of my research project, I have become far better at using SPSS and have in fact been able to better support my supervisor with this application. Another fantastic outcome of the research project is the formation of professional relationships with consultants and researchers. It offers numerous opportunities for participating in other research projects. This is becoming more and more important given the increased emphasis on research and publications as part of many speciality training pathways.

However, the process is not perfect. You may find that ethics applications and approval can be protracted or delayed. Supervisors may not always be available to assist or in fact reply to you emails/correspondence (don’t forget supervisors are often consultants with full clinical duties). Access to patient records, pathology/imaging software may be difficult. Moreover, you may find that you will need further training/support during result analysis as many medical schools do not focus extensively on biological statistics. Nevertheless, all these hurdles are opportunities to problem-solve, manage you time better and appreciate the challenges associated with research.

I personally find it really rewarding but also a highly challenging process.  Managing the full course load of medicine in addition to undertaking a research project can be hard. However, with good time management and setting aside a few hours each week you can make stepwise progress. There is so much potential in these research projects to publish, attend conferences or form strong working relationships with national and international leaders. It makes the entire effort even more worthwhile!

Medical School Practical Classes

Practicals form an important component of learning at the Australian National University and probably most medical schools around Australia. They serve as a platform to apply knowledge learnt in physiology, microbiology, histopathology and anatomy (many other subject areas). Most practical sessions are guided by experienced tutors (who can be your lecturers, hospital clinicians and support staff). There is also written information, questions and prereading that are outlined in practical books that students are provided with at the start of each semester. Lets discuss some of the different types of practicals that are delivered in medical schools.

Anatomy Practicals

In many postgraduate medical curricula anatomy is taught at an extremely rapid rate. At our university we learnt the bulk of human anatomy from head to toe in a matter of several of months. This doesn’t include the radiological component of anatomy and the clinical application. Therefore the practicals were an important part of applying and visualising the anatomy taught in lectures.

In these anatomy practicals  you will encounter wet specimens (ie organs from deceased donors). You will also work with cadavers, which is often a daunting concept for many medical students. I remember, how unusual this concept was especially when you are confronted with an open chest cavity or exposed neck structures. Thankfully the ANU medical school anatomy department eased students into the concept of working with cadavers by covering the donor’s face. After a couple of classes the faces were then revealed. This approach really helped us get used to the concept of dead bodies.

I really enjoy the learning opportunity that is provided by wet specimens. It is useful for visualising the size, texture and anatomical relations of the organs. It is something that is only appreciated in practice, regardless of how much reading and lectures you attend.

Laboratory Practicals

I really enjoy these practical sessions, as they can be so diverse, learning how a diagnosis test works (ie how a pulmonary function test is performed) to running biochemistry analysis of alcohol metabolism. It is really hands on and makes you appreciate how some of the labratory tests that we will frequently order are performed. We also learn how to perform basic ELISA’s for diagnosis of various diseases (ranging from Malaria to HIV). Gram staining and other microbiology laboratory/microscopic techniques are also taught in these practical classes.

For certain topics such as nerve conduction and action potentials we employed computer simulations to help further our understanding. One of my favourite practical sessions was to perform an ECG. It was fascinating to apply the leads, record the data output and interpret the results of fellow classmates.

Some of the more unusual practical classes may involve performing statistical analysis using SPSS. These session tied in with our population health and epidemiology classes. As a doctor it is also really useful to be able to learn to perform statistical analysis with SPSS, which is the industry standard tool for research. You can always impress your consultants by demonstrating a bit of understanding of statistical analysis if you are participating in a research project.

Histopathology Practicals

This has to be far my favourite practical classes. In these classes we discuss both microscopic (histology) and macroscopic appearances of diseased organs and how they manifest. Unlike anatomy which mainly focuses on normal macroscopic structures, histopathology is all about disease states. We are often in small groups and can have a more personal experience discussing various pathological specimens. The sessions are useful because at the end of each session the class comes together and we have presentation on the key learning points of the day. There is ample opportunity to ask questions and clarify points of confusions regarding the subject matter.

Surgical Dissections

At our university dissections are not a compulsory part of our curriculum. Students can elect to participate in dissection classes. Those that have chosen to participate in surgical dissections are required to be paired with fellow classmates. We are then allocated a specimen part to dissect and expose the relevant anatomical structures. Usually the first session is an introductory one, where you are provided with the basic knowledge on how to perform the dissection. Prior to this you will be expected to develop a plan that will enable you to dissect for the specified anatomical structures.

The dissections normally go for several weeks and often contribute enormously to the anatomy practicals as the dissected specimens may become part of the demonstrations. Therefore through this exercise not only do you become more intimately aware of anatomical structures but also contribute to the learning activity of medical students in the future. At ANU the student team with the best dissection is also recognised annually.

 

Problem-based Learning

Problem-based Learning (PBL) is a  key learning modality/style of many medical schools across Australia and globally. Prior to entering medical school I had very vague ideas about PBLs and its utility in the medical school teaching curricula. Having now worked my way through year 2 of medical school, I think I’ve developed a deeper understanding of the advantages and disadvantages of PBLs. However before we discuss the advantages and disadvantages of PBLs let’s briefly talk about what is involved with this learning modality.

PBLs place a huge emphasis on group learning and thus each group is typically comprised of members with diverse backgrounds (particularly if you are fortunate to enrol into postgraduate medicine). Each session is run by tutors who may or may not be doctors. The tutors occupation is not really relevant as their role is to facilitate discussion and ensure the group remains on task. They often help guide the flow of conversation. At the Australian National University, where I’m studying PBL sessions occur twice weekly. The first session usually starts with a trigger. The trigger is much like patient’s presenting complaint. It could also contain additional information about the patient’s past medical history (but frequently this information is absent).

Once the group has orient themselves around the trigger the fun begins! The first part is to develop questions about interesting points/issues about the case or possible research questions that might further your understanding of the topic. You need develop a problem-statement, which is one or two sentences presenting the key essence of the trigger (imagine sharing rapid information to your senior registrar or consultant during a night-shift). Following the problem-statement you’ll then work as a group to systematically assess potential causes and organ systems that may be involved/associated with the presentation. The ultimate aim of this exercise is to develop your differential diagnosis for the case. We then carry out a full history, where the tutor pretends to be the patient. This helps form a deeper understanding of the patient’s history and helps in cementing your differential diagnosis. In the first session you are also provided with a series of questions (including the ones you’ve developed) to investigate and present to your fellow colleagues in the second session. These questions are essentially your learning objective and often correspond with topics discussed in lectures during the week.

The second session revolves around each group member presenting their topic and discussing specific issues regarding the case. In this session we will also look at results for any physical exams, investigations (ECG, blood tests, radioimaging etc..). The result of the investigations then help confirm your diagnosis. To finish off the PBL case you then develop a management plan including any follow-up appointments . The tutor can then discuss the the overall outcomes to ensure no loose ends remain. So as you can see PBL somewhat reflect an approach to treating patients in real world. They also incorporate learning material within the course and thus are important when preparing for exams. However what are some advantages and disadvantages of PBL modality?

Advantages Disadvantages
  • working in a group can be fun
  • Shared learning and contributing to each others understanding of topic
  • discussing complex ideas as a group
  • Fosters team mentality, which is fundamental for the practice of medicine
  • Efficient way of learning when the groups are working and the quality of the posts are good
  • Having PBL food is good, especially if someone is a great cook
  • The quality of the discussion or presentations really depends on your PBL group
  • Variations in tutor expertise, knowledge or personality lead to PBLs of varying quality between different groups
  • Discussions may sometimes get off track
  • Group member personalities may clash (but great opportunity for conflict resolution)

Medical School O-Week

At the start of first year medical students are provided with a really fun and exciting first week. This is commonly referred to as O-week or orientation week. This is as action filled week where you meet many faculty members, get introduced to students in other year levels and most importantly interact with your year level in predominately non-academic situations. The first day, actually the first week of medical school can be a bit daunting and the purpose of O-week is to ensure that you meet as many of your peers as possible.

There are lots of fun activities that are planned both throughout the day and usually in the evening. I really enjoyed the evening events held at our medical school. I recall a quiz night which was lots of fun and we got to interact with other first students in your PBL. Seated at the table were also second year students so it was fantastic to be able to have chat and hear about their experiences thus far. Throughout the day various medical student organisation would hold events, which were usually catered. We were provided with a taste of the diverse range of organisations that we could be involved with such as the rural health, global health and the medical student society.

We also had some lectures during O-week, however these were mostly introductory in nature. We were provided with an outline of topics that we would come to study over the next couples of week. Advice was provided on useful textbooks to help us navigate the complexity of medical knowledge. Overall, the lectures were not critical to understanding subsequent weeks that awaited us. Nor should this be the focus. I think at our medical school more emphasis is placed on social interactions during O-week than academia. So don’t take O-week too seriously. Take it as an opportunity to meet lots of students in your year level and form the initial bonds of friendship.

There is plenty of time for studying in medical school so make sure you make the most of all the fun socialising during O-week!