Week 6: Challenges aplenty

Before we begin: Welcome to the new faces who have subscribed! I’ve got some lovely feedback recently and, even though these diaries are mainly for my reflection, it’s great to hear other people find them helpful, insightful and a tiny bit entertaining.

This week I found myself talking to an imaginary patient, discussing end-of-life pain management and kicking a mother out of a consultation (note: this was a simulated consultation!)

It’s sometimes easy to stay in your comfort zone as a medical student, particularly with a curriculum that can now be mainly completed in your PJs. However, this week I want to promote three main benefits to putting yourself “out there”:

  1. Medicine is full of challenges: Getting used to them early is how you remove some of that fear and grow as a clinician (and person!)
  2. It’s better to make mistakes at this stage: Simulated patients, plastic arms, lecture formats and, ultimately, not quite the accountability you’ll get as a qualified doctor. Now is the time to make mistakes (as long as we stamp out aggressive, abusive teaching methods- something I’m quite passionate about!)
  3. Pleasant surprises: Often, we are far more capable than we realise. Emergency situation? Refer back to ABCDE. Lost in a simulated history taking? Fall back on ICE and open questions. This is complicated by impostor syndrome, anxiety and a non-supportive environment but we don’t have enough time to cover that here!

This week was a mish-mash of lectures, skills practice, communication skills and random patient encounters. Sometimes it’s nice to break the structure of placement and, ahead of 6 weeks of Psych/Neurology, it’s nice to have a slower-paced week!

Backseat doctoring

Communication skills sessions are done as a simulated patient encounter using very talented actors (I’m still waiting for Nicolas Cage to play a disgruntled face transplant patient). This week we were practising triadic interviews (i.e., three people in the consultation), sexual/intimate history practice and adolescent consultations.

During my triadic history practice, I ended up physically standing and ushering the argumentative mother out of the door, which actually got good feedback! For me it was more significant than just enabling a good history with the daughter (the patient). It represented the beginnings of core confidence, a feeling of enough seniority that I can make decisions like this without worrying about seeming “authoritative” enough to do it. There is definitely a pivot point where you start to “feel” like you could be a doctor and, although I’m not there yet, this is a positive step for me.

On the topic of triadic interviews, whilst taking a history from a (real) post-stroke patient, it became apparent that they we speaking to someone who wasn’t there. This is relatively common in the setting of delirium (such as with this patient) and in psychiatric illness, and it’s important not to take a strong stance- i.e., don’t “collude” and agree with the patient that the person is there, but also don’t challenge them on it.

The stroke ward was a difficult environment, but it was so inspiring to see how the nursing staff manage the patients that I ended up posting my reflections on it to LinkedIn. Stroke patients can have differing levels of brain function which can generate frustration and even anger and aggression. It’s not their fault, but it does make even basic things (such as keeping them in their bed) more difficult.

This patient was experiencing hemi-neglect– i.e., his brain only gives “attention” to one half of the field of view. As a result, he coouldn’t walk straight or keep balance, so nearly fell into another patient’s bed area (whilst they were being cleaned!) and also nearly fell of his chair (luckily the combined efforts of me and my student colleague prevented a bad fall).

Despite the difficulties I left the patient feeling better for it: I had been through a difficult history and examination with a delirious patient. In my eyes, this is the sort of patient I want to be confident in managing, and ultimately that will only happen if I put myself in these situations now.

Next week is an “R&I” week, which is “Review & Integration”. Depending on how exciting it is I might write up a blog on another topic and skip the week, but let’s see what happens!

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