The Final Hurdle

As part of  my final year exam at University of Melbourne, I had OSCE and one long case in the last two weeks.

OSCE stands for Objective Structured Clinical Examination. It means that you spend roughly 9 minutes either taking history from an actor or performing a brief but concise physical examination in front of an examiner or interpreting radiological images such as chest x-ray and answering several questions.

Long case means that you are given one hour with a patient in the hospital. In that one hour, you need to know why the patient is in the hospital and to perform relevant physical examination and at the same time, think of appropriate management plan for that patient. You then present your history and examination findings to two examiners. The examiners will be either a general surgeon, physician or a general practitioner. The examiners will asks several questions relevant to the patient and test the depth of your knowledge based on your answer.


OSCE
I had two OSCE at two different location for two days. The first day OSCE was held at the medical faculty and the second OSCE was held at the hospital.

Medical Faculty

1. Patient presented to you with dizzy spell. It was benign paroxysmal positional vertigo. I was not sure what else to ask in this station and was asking weird and random questions towards the end of the station.
2. Interview patient who was referred from Emergency Department to Neurology Outpatient. The ED doctors felt that her epilepsy is not fully controlled. Again, I was not sure how should I approach this station. I have to read the question several times and in the end, running out of time to answer the questions from the examiner.
   
3. Pregnant women who is vomiting. Take history and discuss the differential diagnosis and the relevant investigation. Hyperemesis gravidarum is the keyword for this station. I totally forgot about the intravenous fluid therapy.
   
4. Interpret peak flow chart and teach good inhaler technique to asthmatic patient. Was running out of time in this station.
   
5. Radiology station. CT Brain: Haemorrhagic Stroke. Chest X-ray: Tension Pneumothorax. Interpret lab result: Nephrotic syndrome. I don't have enough time in this station.
   

Clinical School

1. Interview a patient who is feeling unwell. He had malaria. I think I did pretty alright in this station.
   
2. Interview a patient who had recurrent abdominal pain. It turned out the patient had acute pancreatitis. Need to know the differential diagnosis and the relevant investigation. Despite memorising all the causes of acute pancreatitis before the exam, I forgot all the causes due to anxiety attack.
   
3. Procedural skill station. Need to perform airway management and CPR. 
4. Perform cardiovascular examination on a patient who had a murmur. I think the murmur was mitral regurgitation. Not really sure about the murmur since I was pretty nervous thinking the differential diagnosis for both diastolic and systolic murmurs.
5. Perform relevant examination for patient who had right hip pain. Need to do gait, Trendenlenburg test and hip joint examination. After that, need to interpret the hip X-Ray (Osteoarthritis) and discuss the appropriate management of osteoarthritis.

Long Case

I had the opportunity to interview a patient who came in to the hospital with acute asthma attack in the background of nephrotic syndrome (I already had nephrotic syndrome as part of my OSCE).

I don't think I did well in my presentation and the examiners does not ask me any particular question related to asthma management. Instead they opt to ask me questions related to nephrotic syndrome. It was quite difficult since I haven't learned in detail about nephrotic syndrome. When they asked the type of glomerulonephritis causing nephrotic syndrome, I stumbled a bit and just said maybe diabetic nephropathy and rapidly proggressive GN. When they asked me to explain the mechanisms of hypercoagulability state in nephrotic syndrome, I guess this must be my limit. I'm not sure which clotting factors or proteins that will explain the symptoms. I mentioned several clotting factors, protein C and S and antithrombin. I don't know the real mechanism to explain those symptom.

Anyway, up to this point, they haven't asked me anything about asthma. If they were to ask me about asthma, I guess I could do a bit better in my long case.

Hopefully all my friends and I could pass the final year exam and able to graduate together on 5th December 2009.

Anaesthesia

Over the last five days, I have spend most of my time in theatre. As part of my surgical rotation, I need to do a week of anaesthetic.

Anaesthesia is defined as loss of bodily sensation with or without loss of conciousness. There are three main components of anaesthesia, namely hypnosis (being put to sleep), relaxing your muscles and sedation (this means that you lose your awareness of your surrounding).

As a specialty, anaesthetic is one of the toughest training program to get into. There are high level of competition for young doctors to participate in anaesthetic training. It is quite attractive to become an anaesthetist since there are wide range of skills being involved and in term of salary, it has one of the highest salary grade among specialist.

Over the last week, I had the opportunity to practice putting a laryngeal mask into few patients. I had the chance to sharpen my skills in performing intravenous cannulation. 

A laryngeal mask is a tube that is inserted inside your throat during an operation. The picture below shows how to put the laryngeal mask inside your mouth.

 Picture from Merck Manual.

Intravenous cannulation simply means of putting a needle inside your blood vessels. This link will describe in detail how you perform the procedure.

As a medical student, putting a cannula (needle) inside the blood vessel was initially a hard task to be performed. You have to overcome your anxiety of hurting the patient and develop a good technique to insert the needle into a blood vessel.

Anyway, back to my anaesthetic rotation, it was exciting to be at the other side of the theatre. I used to be helping surgeons with the operation and hardly have any chance to sit on the other side. The anaesthetist usually sit behind the curtain and will monitor the anaesthetist machine to ensure the patient is breathing appropriately and is comfortable throughout the operation.

It is interesting to see how the anaesthetist handle the emergency cases. I had several emergency operation throughout the week such as emergency caesarian and emergency laparotomy due to unknown abdominal bleeding. There was a patient who had laryngospasm at the start of the operation and the anaesthetist taught me how to handle this emergency. Laryngospasm is uncontrolled contraction of the muscles inside your vocal cord and will cause a person to stop breathing. This is certainly a dangerous situation since it will cause lots of damage to your organs especially your brain.

In summary, being anaesthetist is fun but at the same time, it is hard to get into their training program. My next four weeks will be in theatre assisting the surgeons with their operation. This will be my last four weeks in medical school.

p/s: I'm looking forward for graduation but at the same time, I've to study hard for the final year exam. Hopefully, I will get a good mark from the exam.

General Practice

For the next 5 weeks, I will be spending time at General Practice (GP) clinic. This means that I will be having lots of opportunities to clerk patient individually and present the findings to the doctor. This will be the best time for me to get lots of procedural skills done.

During winter holiday, the medical school asked us to choose 10 places for our GP placement. Unfortunately, since many medical students choose city placements, not many were able to get their place of choice. In my case, my placement was not even in my list. I was given rural GP placement which is quite far and close to the border of Victoria. I might be celebrating Eid over there as well. There won't be any Muslims within 50-70km radius from my GP placement.Now, that is something that I would call as celebrating Eid'ul Fitr in a foreign land.

I don't think I would be able to get free internet access over there. Hence, no more blogging or even facebook-ing in the next 5 weeks. As this will be my last post before going to my GP placement, please forgive for all my wrongdoings and Happy fasting. Happy Eid in advance too.

Medical Rotation

Alhamdulillah, I have finished my medical rotation. After 5 weeks of spending time following a general medical team, there has been lots of stuff that I've learned yet at the same time, I managed to find out the limit of my knowledge. Clearly, after studying medicine for 6 years, there are still a lot that I don't know.

6 years of studying medicine does not really teach you how to works as a doctor. There seems to be a big gap on how to put all your medical knowledge into practise. Doctors do lots of paper works and referral. Medical school won't teach you how to fill in those paper works. You are supposed to observe it from the interns during this semester and learned it by yourself.

Referring patients to the other specialty is not an easy task to do. Interns are supposed to refer any suitable patients to the specialist for further management. The most difficult part of this process is to answer questions from specialist on reason for referral. I've seen how interns were scared to death when referring to the specialist. If you are not able to answer the questions from the specialist, the referral won't be accepted and you have to tell this to your own consultant.

Many patients who are admitted to the hospital require lots of medical imaging such as chest X-ray, CT scan and MRI. Radiology department is always busy and it is not easy to get a slot for your own patient. Somehow, the young doctor has to plead or find convoluted ways to get permission from the radiologist. Asking for permission to do medical imaging for your patient will always be one of the most difficult tasks for an intern.

Drug chart is one of the most common tasks that every young doctor will do. Yet up to now, I have never been taught formally about all of the doses of the medication. The university asks us to learn it by doing online course.

In the last 5 weeks, I have learned more on how to do my future job more efficiently than learning anything on medical knowledge. Hopefully, my next two rotations will be interesting :)

Gen Med

Tomorrow will be my third week of doing rotation in General Medicine. So far, alhamdulillah, it has been fulfilling. The consultant expects the medical student to participate in the ward round everyday and try to admit patient and presenting on the ward round. The ward round usually lasts between 4-5 hours everyday. It has been busy, but that will be my life starting from next year. So, I guess I shouldn't be the one complaining.

I usually arrived at the hospital around 8am and only came back to home around 10pm. I like to do my revision at hospital rather than studying at home since it can save me lots of electricity bills and prevent me from wasting my time doing unnecessary things.

There are lots of things that I need to revise for this semester. I am still trying to find time to revise my Obstetrics and Gynaecology and Paediatrics since those subjects will be part of my semester exam. Hopefully I can find time to blog and visit other blogs as much as possible in the next few months.

Ok, that's all for now.

Semester 12

This will be my final semester at Melbourne. There will be three rotations during this semester (Medicine, General Practice and Surgery). Each rotation will be 5 weeks and at the end of 15 weeks, there will be 10 OSCE stations and 1 long case.

I am looking forward for this semester since it means that my 6 years of studying in Melbourne will end very soon. At the same time, I am feeling a bit anxious knowing that I will be working as a doctor in less than 6 months time. This will be my transition point from being a student to someone who will be looking after many sick people.

For GP rotation, we were instructed to choose 10 places that we would like to go and at least 3 of them have to be rural places. For this rotation, I was hoping to get somewhere close to home. Unfortunately, I got rural place for my GP rotation. It is so far that I don't think I would be able to return home every week. Hopefully, there will be internet access over there.

My first rotation will be medical rotation and it starts tomorrow. Despite being a final year student, I still believe that there are so many things that I didn't know and I am expecting a busy semester ahead. Hopefully I can survive this semester.

p/s: It is interesting to read what I have predicted 5 years ago. Read future predictions (In Malay)