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In $clinic, coal face medicine.
This past year, medicine is often like a quiz show – BZZZZZ! acute intermittent porphyria, BZZZZZZ what is hypertrophic cardiomyopathy with outflow obstruction.
It’s filled with enzymes, cells, pathological flow charts, and algorithms. The cases exist on paper and we play guess the diagnosis, a la Gregory House.

The doctor leaves, casually tells him to come to see me.
My first patient.
He’s a man’s man. Proudly independent, worked on the land his whole life and still looks like he could take on a bear and win despite being on the other side of 70.
He’s come in complaining of burning on urination.
Score! We just did genitourinary, I follow the algorithm, urine MCS – E coli. treat with antibiotics and treat all UTI in male as suspicious, so take bloods.

His PSA comes back a few days later >20. I close the program. Re-open. Enormous.
Follow the algorithm
We do a DRE. Prostate is hard and lumpy, non tender
Crap.

The PBL case of Mr $prostate is real and is sitting in front of me. We tell him that its probably cancer. We start him on the road of specialists, biopsy and imaging.
He’s stoic, but there is no hiding the concern in his voice and his eyes.

We talked about it afterwards, the doctor is clearly fond of this man, and I had grown to like him over the short time I had known him – his generosity, his direct honesty, his good humour. And now for Christmas we set on him cancer.
He left thanking us warmly, if a little distracted, and strode away, a bit less invincible.

I think it’s easy to get lost in the game of medicine in these first few years. We have little to do with patients, and when we do we often compare who got the ‘coolest’ case. We idealise the super specialists – Charlie Teo, Chris O Brien. Pioneers, giants among men, fighting the impossible fight and winning. We scoff at our Doctor, Patient and Society subjects, giggle at the so-called ’empathy score’, and a good number of students openly deride GP’s professing $chosenSpecialty as superior. We rote learn the method of delivering bad news, regurgitating for examination purposes.
This was not exotic, it didn’t happen in a rarefied tertiary hospital, no machines went ping, there won’t be any books written on it, no superstar surgeons were involved and this story won’t compare to tales of heroism, of snatching patients from the brink of death.
But for me, it was a timely reminder that the cases I learn, the books I read, ultimately it becomes real, the flow charts end with a real person, with fears, concerns, families, loved ones and that I should never forget it.


Angelique Flowers was dying of cancer just before her 31st birthday. She recorded this message for the Australian Prime Minister and asked Exit International to publicise it after her death. She died on Aug 19 2008.

I’m reviewing laws around end of life care, and was reminded of this case from a few months ago. I had a heated argument with a friend of mine over the matter.
It is a topic I am very interested in, and will continue to mull over.
In med school, you can see in people the optimism of science, the primacy of survival. Death is losing, and losing is anathema to these people.
But my thought was that, death is not always bad, there is a dignity in knowing when it is time to move on.

from Angelique’s video:
“I don’t believe in stoicism. I freely admit to not being a brave soul who grins and bears the pain and soldiers on

I deeply admire people who rise above the adversity and their suffering. But I haven’t grown from my illness or become a better person from its torments. All I want after 16 years of painful Crohn’s disease and now cancer is to die a pain-free peaceful death.

“Because euthanasia was banned in Australia I am denied this right …

“We finally have in Kevin Rudd a prime minister who is a person as well as a politician. A man who had the conscience to say sorry to our indigenous people, the integrity to ratify the Kyoto Protocol.

“I beg the Labor Government to continue beating with the heart it has shown and to ensure euthanasia is made legal once again.

“The law wouldn’t let a dog suffer the agony I’m going through before an inevitable death. It would be put down. Yet under the law, my life is worth less than a dog’s.”

So when do you know?

In dance, there are benchmarks, you can see your self in the mirror, on video, you can tell. Or at least, other people can certainly tell. I know when I teach or audition people, I have a pretty good idea of their chances of being a dancer. I have friends who play a game when they examine (they are RAD examiners) on entry, and after the first exercise, they write down your score, put it away and see how close they were at the end of the exam.
You just Know.

But in this medicine thing, you just don’t know. Even if you consider medicine largely one of being a ‘health mechanic’, there are those mechanics who are Talented (to nick Isabelle Carmody’s habit of capitalising the word in the Obernewtyn chronicles. If you dont know what I mean, you should check it out). Who seem to be born to it, the same as a dancer is born to dance, or how any vocation seems to choose its members.
I mean you have exams which are non graded passes, and which don’t really seem to reflect the sort of doctor you may be, or if you are indeed, Talented.
We have had precious little clinical experience, no hands on sort of thing – so we have no idea on our aptitude there either.
(Though amusingly, we had a PBL tutor who told 3 of my friends that they were unsuited to medicine for entirely stupid reasons. eg, one of them, a nurse, said that she found the science difficult, to which he answered that perhaps she could consider ditching medicine and going back to nursing and getting a phd in nursing. Prick.)
Anyways, back to my ramble, how do we know that we are on the right path?
I envy those who have an unshakeable belief in medicine, it would make things simple. focussed.
I can’t help but have doubts.

I had a talk the other day to a proper graduated Dr, who is aiming for otho surgery. I mentioned that I was eyeing of plastics and reconstruction, or some other surgery. He suggested that I needed 4 or 5 good papers published, international conferences, volunteer work, preferably a Masters of Clinical Education, and 10 references to even get an interview.
However, I have no idea if plastics/reconstruction is really for me, its just a rough hunch and something this thing told me, but I have to pretty much gun for it now.
I suppose I can always gun for it, it won’t hurt to have all that for whatever specialty, but dammit its going to make the next few years hurt.

I may have overcomitted 2009 already – currently I’m going to be doing some research in microcirculation, research/development of anatomy teaching using interactive 3d, a commission with the South Australia Museum, a dance performance with the Adelaide Symphony Orchestra. Oh and that medschool thing. I’m also on 2 committees, and probably need to rack up some more volunteer work.
it should make it an interesting year though.

Oh and this being the end of the year, i revisited that medical specialty thing as mentioned and, with my own thoughts, i thought i’d update my list. refer here for the beginning of year thoughts.

So my main ones are still
*surgery – plastics/reconstruction
interesting work, varied cases, suits my attention to detail, dexterity and aesthetics. can also work with kids.
stupendous amount of work… no life

*paediatrics
like working with kids
fairly studendous amount of work

*GP – nice lifestyle. time to have family, make art.

which is fairly consistent. a surprise. I do quite like cardio, it is an interesting field…

anyways, i hope that soon i’ll know. Or maybe I won’t, but hopefully I can feel better about not knowing.

photo of the day:

Dad

‘I’ve nothing against people (to use a vogue phrase) having ’emotional intelligence’ as long as it is allied with ‘intelligent intelligence’. What I am less anamoured of is people diving into emotionalism and abandoning anything else at all’

-‘How Mumbo Jumbo conquered the world’ Francis Wheen

Very funny, do read it if you have half a chance

I was talking to a friend of mine who recently got a job as a research assistant to a law professor looking at we could/should legislate a minimum ‘quality of life’ line to make decisions about who to save/let go clearer and simpler.
They are going to look at whether there is a minimum quality of life, which can define a viable life – where the patient is unable to make their wishes known.

My initial reaction was no – there are far too many factors involved in such a decision for a blanket legislation. Also for something this personal, I really feel the law should stay out – it should provide support for either action, but proscribe neither. But having also had a discussion about death on one of my forum rampages, it did get me thinking.
In Australia, and most western countries, we do shy away from death and the discussion of death.
Death is the ultimate limit, the final failure

“The USA is a nation which tends to find failure shameful, mortifying or even downright sinful…It is a nation of eager yea-sayers and zealous can -doers…American culture is deeply hostile to the idea of limit, and therefore to human biology. “Terry Eagleton, After Theory

Because of this fear and refusal to accept death as simply part of life, perhaps it means we never really engage with the idea of passing during our lives, and causing problems when it comes to treatment at the end of life.

I’ve never had to make the call, and people tell me that often once families see a code, they quickly decide not to call for it again, but I hope that I will gain the wisdom and strength to make the right choice when and if I ever have to.

I’ll probably return to this over time, its one of my favourite topics of mulling over. But here are some other perspectives

A beautiful post which expresses my thoughts far far better than my garbled musings can.

Religious perspectives on withdrawal of treatment from patients with multiple organ failure (Medical Journal of Australia)

To nick a phrase found on Orac’s blog, ‘the stupid, it burns’.
I happen to be a forum and blog junkie and recently on one of the many I visit, an argument appeared as to what a ‘dancer’ is.

Dancers are one of the few groups of people who are so insanely ego-centric that they would get uppity over the correct usage of the designation of dancer. They have elevated it into a hallowed title, conveying an aura of ‘dancerness’, of ability, passion blah blah blah.
So some argue the strictest dictionary application – that dancer is one who dances in public for pay.
Which is patently stupid when considering the rich heritage of other cultures where dance is simply a way of life. The advent of ‘dance’ and indeed ‘art’ as a profession is very recent, these activities have been a part of all human cultures for thousands of years, pretty much as soon as culture developed – from caveman days of rockpainting and jewelry making.
But no, bobbleheads still insist that a professional arts corps is necessary because without it There would be no jane austen, no bach, andy warhol, no great musicians, building would only be functional, walls would all be one colour’ I mean, jeebus, if we didn’t have professional artists, holy jeepers batman, colour would never have been invented!!!!
also highly amusing because one of Warhols ideas was that art is potentially anything one considers to be art. And that art and not art is a blurred distinction

Other knuckleheads content that to be worthy of the term dancer one must have ‘passion’ for it, as if that is a useful definition. You might as well make ‘dancerness’ a criteria.

Interestingly it was only students and non-professional dancers who were all up in arms. My pet theory is that dancers as a whole are so mindboggling insecure that they need a shibboleth to feel secure in themselves and their art. They need a way to differentiate themselves from the mass of the ‘other’.
Or perhaps, as some of them will not assign the title of ‘dancer’ to themselves, feeling themselves unworthy of the title, it is because of the deification of dancers and artists generally – something that John Carey talks about in ‘What good are the Arts?’.
“talk of the immortality of art, in the absence of a belief in God, is childish and self- deceiving”

So its not to be, and it turns out at least some of my fears are justified.

I did not get entry into medicine for 2008.

This blog has not been the joyful trundle I had hoped it would have been. It has somehow turned into another one of those whingy damn blogs which I generally detest, and so may end up shutting it down.

The thing which has me gutted is that I gave it my best, and even now, I would not change my answers in the interview. Which means that 8 people have decided that I am not capable of studying medicine.
The interview was supposed to be what I’m good at, it turns out that my self perception is incredibly off and I have, obviously, no idea of how I come across.

Its a time to really look hard at myself. I have no plans, no options for next year. Maybe October is my month of pain,this is the 3rd year that it has not worked out, 2006, I get sick, 2005 I miss out on the RYD scholarship. 2004, do not get a contract after working with a company and apparently doing a good job.

I know its all random, and I’m just upset right now, but fuck it, I was really hoping that this would work out, maybe that this was something I was meant to do. But obviously not.

I’m off to my good friend scotch. perhaps i will continue to rant later

But i have to keep it all under control as I have a show to do.  I honestly did not expect it to go this way.  I mean I’m supposed to be good at this, talking, communicating is what I do dammit.

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