Master Class

I am a 30 year old professional woman.

I am a 15 year old girl.

I am home for this lengthy vacation because my program offers "conference leave". I blithely fudged a "Marriage Conference"; a master class in parenting, child psychiatry and general medical knowledge. Alas, karma is a bitch. I am now injured, highly parented and having a regressive episode. I am living the master class.

What have I learned so far?

- Physiotherapy is a real thing. I woke up walking like a 90 year old due to a mysterious back pain. After 30 minutes with the physio I was walking like a 70 year old. He snap, crackle & popped me into shape, all the while using vaguely familiar anatomical terms like "spine" and "joint". Voodoo.

- State dependant memory is a real thing. That is, the things you learn when drunk will escape you when sober, but come rushing back next time you have a drink. Alas, high school appears to be a state of mind as well. Sitting around the table with people who saw you go through puberty brings back some startling memories. Mostly involving nudity.

- Regression is a real thing. I am depressingly unable to care for myself when my parents are around. In TO I am on top of my game, baking, washing, working, studying and managing everything with aplomb. In Vancouver, I can't buy tylenol without supervision (who knew there were so many kinds?).

While I am basking in the family time, I am also looking forward to a time where I don't burst into tears at the thought of making a decision. When I get back, I'll be starting pediatrics; once my favourite rotation, now a source of great anxiety (eg: it's all fun & games till someone kills a baby). I am sure I'll look back fondly on this time of being wrapped in a fluffy cocoon of family. I am sure. Any minute now...

theme song

Sometimes we can take ourselves too seriously.

It's easy to get swept up. "I'm a Doctor. I'm doing BIG THINGS. Lives are in MY hands. Blah di blah di blah."

Especially at St Mike's, where we specialize in dealing with marginalized populations; "I work with HIV patients".
"Well, I work with homeless people".
"And I work with people who are both..."

It gets competitive.

It also gets a bit wearing. The responsibility feels too big. The decisions you make feel crucial AND pointless. You get burned out.

Luckily, there's Seaton House. Toronto's largest shelter for men. They let us come in three times a week and we try to do some work. Right now, there are 4 residents and rotating medical students. We residents are all female.

One of us (V) looks like Sophia Loren, wears designer clothing and hates every second that she spends in the infirmary.
One of us (A) has adopted a supercilious attitude (see above) and likes to talk to her patients in what we've come to call "the Mom voice".
One of us (M) is chronically late, loud, inappropriate and (obviously) all her patients adore her. And there's me (S). Deeply cynical, easily annoyed and struggling with my control issues.
We are caricatures.

It got to the point where one of the medical students suggested we write a sitcom about our experiences. "5 girls" was born from a theme song and a snide comment but it has taken on a life of it's own.

Upcoming episodes:
- the one where M realizes she's had glass in her foot for 3 weeks and S tries to take it out without her noticing.
- the one where S finds out her "HIV+" patient isn't
- the one with the cockroach (hilarity ensues)
- the one where V loses it and refuses to see any patients all week
- the one where our supervising doctor reveals that he lives in a commune and has bedbugs

Each episode is punctuated with sassy repartee and girlish gossip.

Plus! The patients! These gentleman alternate between amused and horrified with their treating doctors (fun with racism!). They sometimes disappear on crack binges and don't take their ARVs. They sometimes try to hit on their doctors.

A running gag features the girls trying to work without sitting on any of the chairs (this following "the one where the guy lets his penile discharge drain onto the chair").

Every episode closes with the girls at their favourite sandwich joint or coffee shop, laughing and bonding over their shared experience.

Now, when things get out of hand (when you see the bed bugs, when the rash flakes onto your jeans, when your patient tries to steal your watch) you just turn to the camera, give a cheery smile and sing....

"Fiiiive giiiirls, working at Seaton House!"

Do you binge?

Once a year, the government of Canada would like you to see your family doctor for a preventative health visit. In fact, they would like it so much that they will give your family doc a bonus for filling out the "annual health check" forms.

This is good for many reasons.

1. The annual health check asks the same questions of everyone. It standardizes things so you get the same level of care, regardless of who your doctor is.
2. It creates a framework that can be compared from year to year so you can monitor chronic conditions.
3. Your family doc needs a donut fund so that every day (and not just Friday) has a desk-donut.

The drawback is this: The annual health check asks the same questions of everyone.

My 80 year old patients laugh when I ask them about their libido & recent sexual partners. (Or more disturbingly, they TELL ME DETAILS.)
My 20 year old patients look horrified as I ask them about chest pain, urinary incontinence, haemorrhoids & erectile dysfunction. (But again, there's always one...)

Honestly, the questions that bother me the most are related to drinking.

I feel totally confident saying to my 45 year old patients, "You need to have a maximum of two alcoholic drinks per day and at least one alcohol-free day per week."

But when a 29 year old says, "I don't drink regularly, often go up to a month without drinking, but then I drink 5-10 drinks in one night", I pause.

This is, clearly, unhealthy binge drinking.
This is also my exact answer.

I don't know anyone in my peer group who doesn't drink like this. The days of a drink before dinner and a nightcap before bed are gone. People in my age group (scientific polling of my friends, n= 20) have big nights, pub nights, dinner parties, etc where alcohol is consumed in mass quantities, but they don't drink between occasions.

As a result, I don't know what to say to my patients. I cop out. I read them the spiel of 1-2 max. I suggest that they alternate water with their alcoholic beverages. I vigorously counsel them against drunk driving, unprotected sex, walking alone, and risk-taking behaviours. I give them fistfuls of condoms and test them for STI's & liver damage. I try to explain why they should stop. But I can't tell them to stop without being hypocritical.

As a result, I do not go for my annual health check. Which means that somewhere in Toronto, there's a doctor without a desk-donut, all because I am a hypocrite. But everyone else is doing it...

Turn Into

I had a mother-daughter encounter last week. The 19 year old girl has been having "heart pains" for some time; they're associated with meals, especially eating fatty foods. They cause cramping pain that lasts for up to an hour, sometimes accompanied by nausea & vomiting. The pain is 10/10 when it happens, but there is no pain between attacks.

(Buzz in now if you know the answer.)

The mother was understandably concerned that her daughter was unwell. She sat in the corner of the room and shouted out answers as I asked questions.

"She works too hard! She never stops and takes rest!"
"Her diet is very poor - she never eats vegetables"
"She shouldn't be drinking, right Doctor? Alcohol is bad for young women..."

(It should be noted that these were responses to the questions "How, what, where & when")

At the end of the consultation, as I explained the likely diagnosis and arranged for some tests (Buzz in now for extra credit) the mother stood up and grabbed me.

"You have to tell her she can't drink on the birth control pill. It will kill her."

I actually laughed. I turned to the daughter and said, "If you smoke while you're on the birth control pill, there is a chance it could kill you by causing a blood clot to form and flick off into your lungs. Unfortunately (to her mother) drinking does not increase your risk."

Her mother was not impressed.

It reminded me of my parents. They used to imply that every drink I had was one step closer to my grim death vomiting in an alley somewhere. That staying up past 10pm would lead to clinical depression. That high fat foods would actually stop my heart on consumption. Parents want their kids to be safe, to slow down, to eat well and live good, clean lives.

I am up early, doing homework before heading off to Seaton House. I have eaten a balanced breakfast. I ran yesterday and I am not drinking this week. I caught myself saying to my bf, "It's not that you drink too much, it's that I worry that one day you'll die of cirrhosis of the liver or get permanent brain damage..."

I have turned into my parents. Sigh.

controversy

There was whispering at the nursing station.

"17 weeks? We can't take her!"
"But 4A says they don't know what to do..."
"But it would be cruel!"
"Medical ward might be worse. They don't know what to do with pregnant women."
"But she's 17 weeks..."

The thing is, legally, if a fetus is less than 20 weeks, it can still be terminated (the medical term for induced abortion). Thus, a woman is not pregnant until she reaches 20 weeks. A woman with a 17 week-old is not pregnant. The labour ward only accepts women who are pregnant.

This is the first problem.

The second problem is that this baby was dead.

The woman and her husband had been sent in after an ultrasound showed that their baby had no heartbeat. (And yes, since this was a wanted pregnancy, I will call it a baby). The couple had been sitting in emergency for 2 hours while the wards bickered about who had to take them.

The medical ward refused, saying they didn't know what to do with a pregnant lady.
The labour ward refused, saying the woman was not pregnant, so should be treated medically.

Luckily, the Obstetrician overheard this (we were in the tearoom).

He arranged for the woman to be put in a quiet corner of the L&D ward, away from any newborns.
He arranged for medication to induce uterine contractions so the dead tissue could be expelled.
He arranged for the couple to have a space to grieve for their lost child. When that child was pushed into my hands, he helped me to clean and wrap it, so the parents didn't have to see why their baby couldn't have lived.

I was responsible for checking on the couple overnight. I slipped into their room around 2am and found that the husband had crawled into the narrow hospital bed beside his wife. They had fallen asleep together, his arm across her chest, her arm across her belly. I let them sleep.

I fully and truly believe in a woman's right to choose and easily access termination. Birth and babies are too harrowing and permanent to experience against one's will. But the legal definitions of fetus vs baby are arbitrary. 20 vs 17 weeks vs medical vs obstetrical...

Thank goodness my preceptor stepped over all this and took care of his patient.
"Above all, Samantha, we treat the patient, not the numbers."

It was my last night of obstetrics and I am now thoroughly traumatized. Luckily, I'm back on Family Med now. I talked to a patient about his rough sex practices for 30 minutes. Back where I belong.

Listen to your body...

Alternative health practitioners sometimes use something called "sounding"***. This is where they hold things (foods, medicines, photos of serial killers) near the patient's body and see how the body reacts.

If certain muscles twitch and heart rates change, this object is deemed positive. If other muscles kick in, or you start sweating profusely or vomit, this object is deemed negative. This food/medicine/person is bad for you & you should avoid them.

In short, you are supposed to listen to your body and avoid the things that are specifically toxic to you.

I thought of this last night. At 3am I was curled in the fetal position outside a patient's room. I was using all my energy to not vomit or lose consciousness. I think that baby-catching might not be my thing.

It was a busy day. I delivered 3 babies.

#1 Was a bit of a mess; baby had the cord wrapped around it's neck 3 times, wound so tight we could barely get scissors under it. Still, once babe was resuscitated, he started breathing on his own and should be fine.

#2 I delivered alone. Baby slid smoothly into my hands, parents and I rejoiced, I delivered the placenta and my boss complemented me on my cool. Yay!

#2-b I missed. My pager didn't go off in time, so I ran into the room to hear that sheep-like cry that signals new life.

#3 - I got paged at 2:45am. I ran downstairs. She was pushing. It was her first baby. Her skin was very tight and baby was just not coming. She pushed. She pushed. She pushed. Baby's head kept pressing the skin apart, then falling back. Finally baby came. Meconium in the liquor, baby was silent, but opened his eyes right away. Lots of blood. Lots of tearing. The placenta took a while to come. My boss and I were leaning in to start repairing some of the damage when everything went hot. I realised that I was going to throw up. The nearest bowl was full of placenta. I said, "Excuse me Dr, I need to step outside" and collapsed in the hallway.

Anyhoo, I think this is a sign. Every delivery gives me flashbacks. Every delivery makes me feel unwell. I don't like the smells. I don't like the sounds. The mess. The lack of control. I also don't like waking up surrounded by smirking nurses; don't get me wrong, they looked after me well, but I have yet to convince them that I'm not pregnant. They're already booking my delivery.

So, in conclusion: baby-catching? Not for me.

On to the next block, please!

***Don't quote me on this. I learned about sounding from a high-school friend who now practices as a HORSE naturopath. She uses this technique on horses. HORSES!

How to have a baby:

2009 was the last time I tried to catch a baby. I was young and keen, with catlike speed and reflexes. I dropped her.

(Full disclosure: baby was being born onto soft mattress, fell only 3cm, was caught on first bounce, no harm no foul.)

I am supposed to be baby catching this time tomorrow night. I am older, slower and definitely more sleep-deprived. I am frantically trying to relearn the many components required for successful vaginal delivery.

The textbooks say "Only 3 things are required for successful labour: power, passage & passenger."

Power = uterine contractions. Apparently 3-5 in ten minutes is adequate, but there's no real science behind this rather blase statement.

Passage = um, the birth passage. Any obstructions, like say, YOUR SOFT TISSUE, will be rent asunder by the force of your uterus pushing an entire person through an inflexible space and...No, no, no. Calm down. Generally it works out. As long as your bones are wide enough to pass a head, you're fine. Ish.

Passenger = the important bit. The reason we're all here. There are one or two things that need to be perfect if Baby is going to be perfect:

1. Lie: longitudinal, transverse, oblique. (hint: transverse = bad)

2. Position: the way the head points - it should come halfway out at OT, then (like in the Exorcist) rotate spontaneously before shooting out at high speed in OA position.

3. Presentation: the bit that comes out first. Hope to see the back of the head. All else is doom.

4. Attitude: a real problem in kids these days. JK, attitude is the way they're flexed - if you see a chin first, that kid has BAD attitude and will need a caeser.

5. Station: how far into the pelvis we are. -1 is approaching the hole, +4 is leaving the building.

6. Size: less than 9lbs would be nice. More than 9 and we start to have tears. Rhymes with beers tears and rhymes with cares tears. So many tears. Note to self: don't date men who brag about what big babies they were.

Also, if there is more than one baby, or baby has devil-horns or a tail, this will make things interesting. If things are interesting, something's going wrong.

So there you have it. Three simple components, each with 3-5 sub-requirements, 6 caveats, 4 additional notes and a partridge in a pear tree. Having babies is hard.

Making babies? That's a whole other post.

Blip!

This post was composed last week, but I got called to a trauma before I hit send. I'm leaving for NYC to meet up with my favourite people (Banana! Dan! Sally! Randy!) and will be back in 2 weeks, ready to tell you all the gory stories of baby-catching in Scarborough!

Suddenly, it is the last week of my surgical rotation. I am hiding in the call room at 9am, wearing 3 pagers (plus my phone). This is what I have learned after a month of surgical training:

1. Always hide in the call room. If you're on the floor, nurses, case managers, dieticians & patients can see you. And then they can ask you, "Just quickly, just one thing...". This will prevent you from doing your real job.

2. Your real job is paperwork. Every single patient needs an admission note, progress notes, prescriptions, diet plans & discharge summaries. If you are not a surgical resident it will be assumed that you love paperwork. This assumption is false. But you will do it all anyways.

3. You've got to carry the trauma pager. On my first call shift, I was terrified about being first to arrive at a trauma, which would obviously result in a spectacular and immediate patient death. Now, in my last week, I am trying to carry it as much as possible. Trauma work is teamwork (yep, there are tee-shirts) and there is always someone there to stop you from killing people. Well, so far.

To quote Strictly Ballroom; "A life lived in fear is a life half-lived". And that's just not on.

4. It is possible to get sick of Tim Horton's breakfast sandwiches. I never thought it could be true, but one a day for 21 days in a row (yes, that's how much I'm working) and I have started to feel ill at the thought. I am still eating them, but now I feel a little ill as I stand in line to order the next one.

5. I am not a surgeon. I love the cutting, love the blood, love the clean & decisive management. I do not love the hours, the turnover, the death rate or the hours. I am, for better or worse, a family doc. At least until my next rotation...

Trauma Team.

On my current surgical rotation, sometimes I carry the trauma pager. That means that if a trauma arrives at the hospital, I go down to Emergency and become part of the team who deals with whatever comes through the door.

My first trauma was a young guy (15) who had fallen off the back of his friend's motorcycle. He was wearing a helmet (thank GOD!) so his major injuries were a distinct loss of skin and multiple fractures in his hands. This was a good trauma.

Yesterday we had another young patient. At 2 in the afternoon, she was crossing the street in front of her house and was hit by a car going 40kph. She was thrown through a fence and knocked unconscious at the scene. I was cutting her clothes off (to expose any hidden injuries) as they assessed her pupils; both blown. The CT scan showed a massive intra-cranial bleed. We put in a chest tube, then sent her up with the neurosurgeons to have her brain drained. I don't know for sure, but the consensus was that she would not live. This is a bad trauma.

I am loving this job; long hours melt away when you feel that you are doing valuable work. And when you are involved in these high-tension situations, every nerve comes alive and you function at a higher level than you knew possible. However.

However.

I was lying on my bed last night, reading trashy comics, when I closed my eyes. The sight of trauma 2's broken body appeared in my head. I had to call the people I love to make sure that they hadn't been hit by cars. I dreamed about the push of forcep & tube into the chest wall.

There are some drawbacks to this career path.

2 weeks till babies. Perhaps that will be less traumatic.

family business

On Friday, I saw 12 patients. One patient for each half-hour appointment allocated to me in a day.

This is, roughly, about half the number of patients seen by a senior family medicine resident.
One third of the patients seen by a regular family doc.
Walk in clinic doc? 6 patients an hour.

I meet these people, hear their life stories, hear the secret dirty/horrifying/shocking parts of their life stories, then figure out what to do for them, document it all and kick them out the door.

As a random sample of Friday's patients I had a morning-after-pill, a post-female-circumcision PTSD patient, a psychotic young guy who asked me out for the weekend, a depressed patient who simply cried for half an hour, plus several adorable babies.

By Friday night, I was utterly spent.

I know it's wrong, but I couldn't muster the energy to interact with my friends. Going out, sitting down and asking them "How are you today?" seemed way too much like work.

For years, I thought my Dad was nuts; he prefers mindless physical tasks or chores to socializing. But now, having spent my Saturday night cleaning my kitchen, listening to music and not talking or listening to anyone, I get it. You run out of steam.

I'm not sure how I'll cope next year - 24 patients a day? For serious?

Incident Report

My patient this afternoon was a young woman. At 25, she had never had a pap smear, so I carefully explained the procedure, making sure to reassure her that a) it should not be too uncomfortable and b)it would be over quickly.

We got started. In soothing tones, I talked her through the steps;

"I'm just going to place my hand here. Take a deep breath, try to relax..."
"I'm inserting the speculum now. Deep breath, try to relax..."
"I'm just getting the first swab. Deep breath..."

There was a crack. I turned back. The plastic speculum had broken. Shattered, actually, against the pressure of her internal musculature. I maintained the soothing tones.

"Ok, so that noise you heard was the speculum breaking. That doesn't normally happen. Are you feeling alright?"
"Um, it's a bit uncomfortable."
(No shit! Holy jesus, your ladyness is full of sharp plastic shards! I'm surprised you're not screaming!)
"Alright, love, I'm just going to remove those bits and put a new one in. Deep breath, try to relax..."

We got through it, but I'm pretty sure she's traumatized.

Hell, I'm traumatized. I never want to see another crappy plastic speculum as long as I live. I told my boss and she baulked. Actually flinched. We exchanged glances and said, "At least she doesn't have to do it again until next year..."

The job may not be glamorous, but it's never boring.

more than family...

There is an incredibly annoying water bottle that my bosses carry. It's a PBA-free, all stainless steel, sustainable, caribeener-to-your-fixie-bike model. Conveniently sized to fit into a messenger bag. Just like every other hipster water bottle in Canada. However, this is not the source of my irritation.

This water bottle has a message on it:

"Family Medicine: more than family, more than medicine..."

I roll my eyes every time I see this.

But:

This week, I got sick. I woke up feverish, sore, sniffling and miserable. In Australia, this happened during my Rehab block. I was very, very, unwell but I did not miss a day of work. If I had, I would be looked upon as weak. Not pulling my weight. Letting down the mates. Etc. Etc.

On Monday morning, I sat in my teaching session, trying to snivel discreetly. After an hour, the head of Family Med stopped the lesson.

HFM: "Sam, are you sick?"
Me: "Urm. No. I'm just coughing up lung butter to demonstrate my understanding of URTI's"
HFM: "I think you should go home. You need to rest. Cancel your clinics."
Me: ....
HFM: "Off you go. You need to look after yourself."

I reeled for a moment.

Then I went home. I looked after myself.

Today, I am still sick. I went to my clinics, supported by a drug cocktail that (upon further research) is essentially crystal meth. And I got through the day.

Until 5pm, when we usually meet to discuss our patients. My preceptor, who is also sick, took one look at me and said, "Go home. You can't learn when you're sick. Call in sick tomorrow if you need to. You need to look after yourself."

More than medicine. More than family.
This job might just be good for me.

em-pathetic

There is a huge and fascinating article in today's Globe & Mail about empathy. It's loosely focused on the recent tragedy in Norway and explores the idea that "evil" in people can actually be attributed to a lack of empathy.

The researchers interviewed discuss situations where people (and animals) display a lack of empathy; chronically, such as in people with Autism, or acutely, in the case of torture or murder.

I have previously gone on record saying that my clinical medical skills improved when I learned to suppress my empathy.

As a medical student, I had trouble placing drips (IV's). I would wince as the patient winced. I would break into a sweat, fumbling, jostling the tip and carving up their delicate vessels. Then I'd have to find another vein, and repeat ad nauseum.

When I learned to shut my empathy down, I found I could treat the vein as an isolated problem. Yes, I can hear someone wailing and moaning and carrying on, but I just have to slide this needle into this tube and get some red stuff. Smooth as. No worries.

In the article, they talk about people who can spontaneously shut off their empathy in morally difficult situations. These people are sociopaths.

Luckily, in family medicine, I rarely do procedural stuff.

I do, however, hear about 20 sad stories a day. Some things are horrifying; surprise pregnancy with a side of surprise HIV, domestic violence, sudden death and disease. Some things are less extreme, but just as devastating for the people going through them. I ended up comforting a jilted lover for 40 minutes as they sobbed into my tissue box. (Your tax dollars at work.)

Here, at week four, I have run out of empathy.

Not at work - I have an endless supply of sympathetic nods, heartfelt sighs and respectful, supportive, asexual shoulder pats.

My lack is coming through at home. I don't give a shit.

Worried about your career trajectory? I could care less! Your haircut doesn't flatter you? Suck it up! You're just not sure if he likes you enough? Blow me! And that's just self-talk. My friends get it worse.

I read the article thoroughly, looking for people who get empathy-depleted. Not a sociopath, not yet Autistic. I wanted to know that burn-out doesn't necessarily lead to mass murder. Alas, I couldn't find anything to soothe.

In order to get my empathy back, I'm going to watch kitten DJ's all night. People can be harsh, but kittens never let you down...

Three Oh.

Officially old. But not, unfortunately, mature.

I am truly grateful that every year my life gets better and better. When I'm 95 (Happy Birthday Gran!) I will be having more fun than is physically possible. I can just feel it.

Time to dance!




En espagnol!

Love!

Monday is the worst day, right?
Not so! Not if you're living the dream that is family medicine.

On paper, it was a typically crappy medical day:
8 -12: "Evidence based medicine" (eg: reading journal articles aloud to each other) followed by "Behavioural medicine" (eg: social worker reading journal articles to us).

1-5: Clinic (eg: poking sick people & their icky parts)

5-9am: Call (eg: pager panic)

BUT in reality:

8-10: Immunization Trivial Pursuit
Seriously. Our program director (and head of U of T family med) actually made a Trivial Pursuit board game with questions about various vaccines. I believe the green was Diptheria, blue was Hepatitis and orange Varicella. I learned a tremendous amount, though I couldn't shake my craving for a G&T and some Pender sunshine.

10-12: Social work articles? Nope! Parenting lessons! And thanks to my father's professional tutelage, I had all the answers.

This relates to the time Dad asked brother & me to make a powerpoint on parenting for his students. As we turned his notes into slides, we exchanged worried glances. "Time outs? Neutral language? Psychological discipline? We've been parented!"

1-5: Clinic! Transgendered alcoholics begging for rehab! Tiny kids with sore ears! Swabs for lesbians with cheating lovers! Medical marijuana for HIV positive old dudes!

And as for call...

As of 10pm, I have taken some pages, answered some questions and done some reading. All from the comfort of my own home. With take-out tacos. In my undies. (34 degrees here).

I love my job.

a day late, a buck short?

Strawberry Rhubarb Pie.

From scratch. Pastry & all.

I feel so wholesome that I'm compelled to go out dancing in trashy bars with drunk doctors.

summer fun

When you have warm summer evenings, the smell of jasmine coming through the window and humidity-curled hair brushing at the nape of your neck, you know you're on vacation.

To fill your empty hours (and cos the strawberries are rotting in the box) you can make pie.















Of course, when you have the attention span of a five year old on red cordial, you may only make the pastry and the filling, then get distracted.

You will go across the street and steal DVDs from Ian. Come back and admire your toenails. Google "rhubarb poisoning" and think about the legal definition of "criminal intent". Stew the rest of the rhubarb. Realize that you only have enough pastry for a bottom crust. Realize that you've run out of flour. Give up, google Dashboard Confessional and listen to summer songs.



Toronto in summer is awesome. I'll never work here; there's too much else to do!
I'll finish the pie tomorrow.

summer fling!

I don't know what to tell you...

I've finished the PRP. (Pre-residency program, aka "teach Sam to speak Canadian"). I have a small, perfectly formed apartment. My hospital feels like home. I've met my bosses. I am excited to be a family doctor. I have new friends. I've found the good coffee spot and shamelessly hit on the proprietor.

It's been a busy 3 months. Aside from getting peed on by multiple infants, I have no recent medical stories. July first will be my first day as a (legal) Canadian doctor.

I'm going to lie in the sun listening to summer pop until then. Join me!

cupcake

Like most people, I love talking about sex.

There is something so compelling about the ins and outs (!) of human relationships. And this is why I love my job. I meet someone and immediately ask them to describe their most recent sins. I especially enjoy the matter-of-factness that the doctor's office allows.

Do you have sex with men, women or both?
Are you currently sexually active?
Do you have a monogamous relationship, casual partners or both?
Oral, anal, vaginal or other?

Just ticking the boxes Ma'am. All part of the job.

And the answers! I don't pretend to be a wildly experienced woman, but I do read a lot. My most depraved literature can't compete with the day to day transactions of love.

For example: My MtoF transgendered patient can't maintain erections (due to hormone therapy) and asked me for any suggestions on what to do. Her partner is pre-op MtoF trans and I had to ask exactly what components were on offer. And then think about it. And then google it. We came up with some ideas, and she'll report back. I hope.

Other fun sexy-times? Papping a pregnant lady. Diagnosing genital warts. Demonstrating correct condom usage techniques. Googling "poppers" and "bear clubs". Using the words "insertive" and "receptive" in daily conversation.

Don't get me wrong. I am not just a sex-obsessed prevert.

I also really enjoy baking.

Things I heard at work today...

- Bye ladies!
- Those aren't ladies, they're doctors.
- Oh. Bye doctors!

"Dress code? Um. It's a men's hostel, so don't wear anything that makes you look cute. Or anything that can't get barf on it."

"I tried to listen to his lungs, but then a bug crawled across his back, so..."

"When is it safe to have sex after having a baby? Well, a gentleman waits until the episiotomy is sewn."

"It's a good idea to build trust before sticking your hand in someone's vagina."

And so on and so forth.

Another exciting day in the life of...well...what ever I am.
Not a medical student, not yet a doctor. Legally anyways. Which means everytime my boss introduces me as Dr Marriage, and I don't correct him, I am committing a felony.

Anyways, we had obstetrics lectures with an amazing doctor today. She swore, she made inappropriate sex jokes, she told us she'd been kicked out of two different residencies before she found her calling in Family Med and was candid and blunt about how baby-catching both sucks and rocks.

I have a new hero.

mumsy

People often refer to specialties as having personalities. For example, at St V's, the surgeons were brusque, competitive and hyper-masculine. The medical folk were the intellectuals of the team. The ED physicians were the kid running around the back of the classroom after drinking too much red cordial.

I am noticing that different facets of my personality come out to play when I'm immersed in different specialties. Doing internal medicine (in the country) brought out my dispassionate, methodical scientist. I became pragmatic about prolonging suffering, and so convinced more than one patient that it was time to let go.

When I was on cardiac surgery, I behaved like a crazed femme fatale. Stalking about the ward in dresses and heels (when I wasn't in scrubs) I would flirt with my patients while telling them that there was no problem we couldn't handle. Atrial fibrillation? No worries. Chest pain? I can handle it. Cardiac arrest, opening the chest on the ward and hand pumping until we get to theatre? Doesn't faze me. I projected an aura of absolute confidence, wrapped in swishy silks. Then I would go home and cry.

Family medicine is bringing out a dangerous, unfamiliar side. My maternal side. I listen to my patients and I want to hug them. To feed them. To help them get their lives back on track. This is, surprisingly, a problem. My patients this week have been crack addicted felons, meth-heads who are high WHILE I'm talking to them and HIV+ guys who think bare-backing is ok as long as they come "outside". These are tricky people to help.

Still, there were some good moments. Showing a guy the latest cool condoms (courtesy of Trojan) and seeing him take a fistful home. Having my patient shake my hand and thank me for listening. Even the meth-head said, "This was a good day, doc..."*

I suppose that I was initially concerned with the ambiguity, or "soft" side of family med. I was worried that I'd stop being a doctor and turn into a mom. A big, softy. It turns out it's not that simple. Even when you're suppressing the urge to pat everyone on the head and call them "love".

* He followed this with "cos I had 3 women looking at my dick". I choose to only hear the first bit.

pro: tiny wiggly butts

Babies can have so many different rashes. The Resident and I spent a good portion of this afternoon comparing rashes and Australian/Canadian terms for rashes.

What she calls a cherry hemangioma, I call a strawberry haemangioma.
What she calls lace-like, I call reticular.
When I say "Mongolian blue spots" she shudders. Slate-blue naevus is the PC-approved term. I don't suppose the Mongolians would mind, but hey, this is Canada!

My new home/clinic specializes in LBGQT (?) patients, new immigrants, the homeless and tiny, tiny babies. I was at work for 9 hours today. I did not get paid. Will not, in fact, get paid for my next 6 weeks of service. But I had a great day.

I love my job. I love being at work. Even for no pay. Even though they introduce me as "the IMG sort-of doctor".

I had forgotten how much fun medicine can be. Dr G is back in the hizzouse.

when animals attack

So, this thing happened to me during the LMCC.

(Background: LMCC is the Canadian medical licensing exam. It is a 9 hour, computer-based exam. The morning consists of 200 multiple choice questions. The afternoon gives you roughly 50 cases and you write in answers based on said cases. Phew.)

The case was vague. An eleven year old boy is hiking in the woods with his family when he suddenly becomes ill. He is pale, sweaty and his heart is racing. By the time he gets to you (ER) he is unresponsive.

I read this and though, Oh! Easy, right? This kid has obviously been bitten by a poisonous snake or spider and is going into respiratory failure.

But. BUT. This exam is set in Canada. There are no poisonous snakes in Canada.

Or are there? Are rattlesnakes are part of the Canadian fauna? Surely copperheads can migrate across the border? No. But what if there is another kind of snake?

The exam board is from Ottawa, are there poisonous snakes in Ottawa (insert political reference here) or do they have ticks or other insects I'm not familiar with?

But! What else would it be? There are no signs of anaphylaxis (swelling, wheals, stridor). There are no indications that the kid has an underlying disease. It must be snake-bite.

But what snake would have bitten him?...

I went round like this for a while. Specfically, for ten minutes and thirty seconds. (You get a time breakdown of how long you spend on each question. My average was 32 seconds. This ten-minute blip was not reassuring.)

A similar thing happened during my last Canadian exam. The question was about frostbite. I sat in front of the screen blinking and mumbling to myself because in 4.5 years of Australian med school, frostbite had never come up. Blue ringed octopus stings? Sure. Lethal sunburn? Absolutely. But no frostbite.

With luck, I will have passed. If not, I'll write the damn thing again.

In the meantime, I get 6 weeks of "integration to the Canadian medical system", which will hopefully teach me the herpetological biodiversity of Canada.

I'm sure that's a priority.

home

I get off the plane and see my parent(s) waving at me, Tim Hortons in hand. They will immediately try to take my bag, feed me and tell me that the phone hasn't rung since last time I was home.

My Dad will suggest that any and all complaints can be solved by going to the gym. I will go to the gym with him and as we leave he'll say, "We should go again tomorrow".

Desi and I will drink too much coffee and talk for 5 hours without pausing, then decide to take a joint nap and watch 30 Rock.

J&K will suggest drinking, hockey or a combination of the two. We will yell at the TV.

Tippi will confuse my parents with his grown-up voice. "I didn't recognize him! He said it was Geoff! Who's Geoff?"

The 6 week English communication course is done (spoiler: I passed) and my licensing exam is a a faint PTSD nightmare. I am an official grown-up employed person. I am living the dream.

Still, it's nice to know that Vancouver is here. A place where I am not responsible for anyone else. Where I don't have cause pain, break bad news or tell people what to do. I'm embracing the regression to my teens. I'm going to stay in my pajamas until 2, then go to Dairy Queen for a blizzard.

God Complex II

I just hung up the phone with the Warrnambool Police department. They sent me an email (beginning with G'day and ending with Cheers) and asked me to call urgently.

I, frankly, suspected that they had traced my speeding fines back to my invalid Canadian license and were planning to charge me with unlawful operation of a motor vehicle. It was much more interesting than that.

Last year I saw a patient after an assault. The police are pressing charges against the assailants and wanted me to appear in court.

"I'm actually in Canada right now."
"Too right, are you coming back?"
" Well, I'm here for at least 2 years for a training program."
" Ah, good on ya, love. No court for you. Thanks for calling back."

Two things:
1. All the medico-legal stuff we've been covering has become startlingly relevant. Just this week we discussed our obligations towards court appearances, documentation and what to write when dealing with he-said-she-said.

The cop said that they have my notes. I remember the night clearly. It was late, I was over-caffeinated, the only doctor on and surrounded by drunk & violent patients. I am worried about my notes. My delirious scrawl might put someone in jail.

2. I really miss Warrnambool. Seriously, it was the best place to work. The people are friendly, the job was interesting, the Cops are cheery and they had TWO amazing burger joints within walking distance of the hospital.

Incidentally, we covered medical error in class today. This is where we (doctors) make a mistake and and you (sick people) get hurt. We apologize, and depending on the quality of the apology, you may or may not choose to sue.

I think back over my last year of wrong drugs, missed drugs, "chest-tube-in-the-liver", unnecessary transfusions and unnecessary operations. I worry. There are only so many countries I can flee to. Ah well. The cops will track me down eventually.

power play

Life is short. So short that last week I found myself sobbing in my program director's office.

The background:
The acting lessons have continued. They have, in fact, escalated. We are interviewing fake patients up to 3 times a day. After EACH and EVERY interaction, we are asked, "What communication skills did you use?", "What made you choose that communication skill?" and "How did that make you feel?".

I have been communicating exactly how this makes me feel.

For example:

"I feel that you have a different agenda than I do. I care about talking to my patient, you care about my ability to identify what communication strategies I am using when talking to my patient. If I think about what strategies I'm using, I stop listening to the patient!" (mild)

"What strategies have I used? Listening and responding appropriately." (moderate)

"I DON'T CARE ABOUT THE COMMUNICATION, I CARE ABOUT THE CONTENT!" (severe)

When I emerged from the ladies room last Tuesday, the program director was waiting for me. "Are you Samantha? Can I have a word?"
"Am I in trouble?"
"No! Don't be silly. I just want to get some feedback from you..."

She took me up to her office and assured me that this was a safe space, that I could give her honest feedback and that she was on my side. She then told me that there had been complaints from the actors. Complaints that said I was impatient. That I seemed bored. That I seemed frustrated.

I nodded. "Yes, I am bored. I find this course extremely frustrating and boring."

Awkward silence.

She started again, "Are you having personal difficulties in your life? Is that why you're frustrated? "

"No. No! I am angry because three months ago I was a respected professional and now I am being asked to perform skits on the meanings of common English words. I am frustrated because I have been effectively communicating with patients for years now. I am bored because we did simulated patient interviews in medical school."

Silence.

"Well, we're on your side. We know that you speak English. And we acknowledge that you don't need to be doing this communication course. And we know you know how to talk to patients. But..."
"But?"
"But the actors have the power here, so you'd better pull your head in or go home."

At this point I was so angry that I burst into tears. Life is short! I have no power! This course is 6 weeks of my life that I will never get back!

The program director visibly perked up at the sight of me crying.

"Oh, you're upset! Would you like to go talk to the actors now? Cos I'm sure they would really love to respond to your emotions..."

That's right little monkey. Cry for the actors. Cry so they may relish your misery!

It's been a rough week. Thank God for long weekends. I need an Easter basket.

Up for the challenge...

In Cutting for Stone, the protagonist says, "I thought I should do the hardest thing, so I picked surgery".

Last week, we did (more) interviews with simulated patients. One person interviews, three people watch and we cycle through the group. On Monday, the theme was "boundaries". The first patient had latent homosexual tendencies and was ashamed. The second patient was having an affair with her boss. The third patient was mine.

She was a chatty, overly friendly person who reeked of loneliness and desperation. Throughout the session, she repeatedly invited me out for coffee, touched my knee, insisted that we would be best friends and asked me for details about my personal life. A classic case of boundary violation. A possible borderline personality disorder.

I repeatedly, politely, stopped her: asking her for more space, deflecting the conversation from me to her and explaining that our doctor-patient relationship prevented us from engaging in social contact. She didn't let up.

Borderline personalities are characterized by unstable and intense personal relationships, frantic efforts to avoid perceived or real abandonment, impulsive behaviours and frequent attempts at self harm. In short, unstable, clingy and bat-shit crazy.

The third time she ignored my "stop" I panicked. I totally freaked out and literally got out of my chair and walked away from her. From an actor.

On Thursday, I was assigned to interview an acutely psychotic patient. He was obviously hallucinating, terrified of what he was hearing, and stated that I was one of Satan's minions. Again, I freaked out. This time, there was no touching, no disrespect, no violation, just pure and simple madness. The hair on the back of my neck was on end. Again, just an actor.

Aside from these two interviews, the rest of the course has been easy. I am good at sex-talk, depression, prostates and poo. I am good at communicating with most people when it comes to their health. Severe mental illness I find utterly confronting and am unable to cope with it.

I think I have to go into psychiatry.

Lock up your daughters...

Boundaries. When is it ok to touch your patient? When is it ok to tell them personal things? When can you buy them a coffee? When can they give you a gift?

Today's lecture on doctor-patient boundaries was startling, relevant and occasionally hilarious ("I don't know how it happened, but suddenly my penis was in her mouth!").

I have some things to consider, especially in my approach to giving medical advice to friends. Apparently, I shouldn't. This may improve my experience at high-school reunions, where I have previously been asked about rashes, fertility and (by one particular ex) "this pain in my balls". It may also limit my social success. Without these answers, I don't have much to say to some people.

I digress. The take-home message from today's lecture was this: It IS okay to date your patients.

Seriously. New Ontario legislation states that as long as you terminate your doctor-patient relationship prior to commencing a sexual relationship, you are in the clear.

"I don't want to be your doctor anymore. Now take off your pants."

Where's a medical defense lawyer when I need him?

Your word is "validate"...

"We'd like you to get into small groups. Each group will be given a word that relates to patient communication. We want you to define the word, and then create a skit to demonstrate your definition to the other groups."

Rage blackouts all week. Seriously.

There was a special presentation on Thursday evening; the provincial health minister and minister for immigration came to congratulate us on our new jobs. Due to the upcoming election, CBC and other news outlets came to cover the congratulations. For roughly 45 minutes people got up to say things like "We appreciate the cultural differences you bring to Ontario" and "We're so thrilled that you've decided to make Canada your home".

After the presentations, I spoke to the ministers individually.

I asked, respectfully, if they were aware that more than 50% of the people in the program were Canadian born and raised. If they were aware that most of us had only left the country for medical school; usually 4-6 years out of country. If they knew that we were being forced to learn (at taxpayer expense) how to speak English. If they knew we were being sent to isolated Northern outposts for 5 years.

Minister for Immigration (a medical doctor) said, "That does seem unnecessary. Unfortunately, it's not my area, but it's good to know about. Thank you."
Minister for Health said, "Oh wow. Well, I feel your pain. My sister-in-law is training in Australia right now, so..."

When I pressed her for planned changes to the program, or her thoughts on whether this matter was fair, she looked annoyed. "The program has already improved so much! It was much worse before!"

So there we have it. English speaking Canadians are doing skits about communications at YOUR expense.
You cannot have an Ontario trained doctor in BC (where there is a greater shortage) cos we are indentured for 5 years. For a 2 year training program.
Canadian citizens are being punished for funding their own medical training when the oversubscribed Canadian system can't fit them in.

Please, write to your elected representative. Action now may prevent your future doctor from being deported for drunken and disorderly behaviour towards Provinical ministers.

Psychiatry for a better tomorrow

Today's lesson was "Canada's Health Care System: Community, Caring and Sharing". I could feel various symptoms drifting through me as the day dragged on.

First, paranoia: This is a joke. They're trying to fuck with me. There's no way they can make me sit through a 6 hour session on caring and sharing. I'm not five. They're messing with me...

Next, avoidant behaviours: I could just get up and leave. I could be on a plane to Melbourne in 24 hours, back at work at St V's within a week. I'll break my lease, abandon my new bed and walk away, never come back to Canada again!

Then, denial & distraction: La la la, I can't hear this woman telling me that the most valuable tool I have are my ears. Instead, I will go on twitter and read about Ian at the Junos. I will look for couches on Craigslist. I will urgently try to text people in Australia. Because if I don't pay attention, I don't have to acknowledge that this is happening to me.

Finally, psychosis: All these motherf**kers are beneath me. I will use my lazer eye-beams to fry them in their skins (extra-crispy!) and then fly out the window. To New Zealand. Where I'll join Bert on the Tongariro Crossing and we'll eat all the scroggin we can carry.

I suppose the silver lining to these nuff-nuff classes is that they allow plenty of time to (covertly) read my textbooks under the table. Today's topic? Identifying psychiatric disease. Handy.

interesting medical words I learned today

Marsupialisation: the act of slitting an abscess, then suturing one edge to the base to create a pouch of tissue, thus allowing free drainage of the pus.

From the word "marsupial", referring to a (generally Australian) mammal with a pouch.

I did not learn this in class. In class, I learned that crossing one's arms is a sign of "closed" body language. And that the teachers have surprisingly good hearing when it comes to cuss words.

Luckily, my new friends are just as profane and cynical as me, so none of us could be pinpointed for blame.

At home, life is still blissful. I'm watching the snow come down, eating marshmallows and learning about the different types of vaginal discharge. Which is not everyone's cup of tea, but works for me.

first day

This is not a repeat of medical school. We know that you have all been to a medical school somewhere.

This is not an English class, you have more than proven your abilities in English with your...with the tests...your English skills are fine.

This program is designed to help you prepare for your integration into the Canadian medical system.

Apparently, integrating into the Canadian medical system involves talking to actors who play simulated patients. Something you may remember from first year. First year. SIX YEARS AGO.

Anyhoo, my first day of school involved shiny new pens, highlighters, file folders and that old sinking feeling. It's not that I mind the program. It's mind-numbingly useless for a convincing pseudo-empath such as myself, but it's not hard work.

What I mind is that it's taking away from my exam study. Y'know. The actual medical knowledge. The stuff I used to know, but that has apparently dissolved in my weekly alcoholic brain-baths. The stuff that might save a life.

I came home today and tried to study, I swear. But the soft couch & fluffy cat pulled me in, then Godfrey suggested breakfast tacos for dinner (necessitating a trip to the shops) and then, suddenly, it was 9:30 and I was full of cheese. No room for facts.

I'll try again tomorrow. After my "Learn to use a Library" session. Sigh.

Bert the careful turtle...

Culture shock is an alarming thing, never more so than when you're returning "home". I had somehow thought that re-integrating into society (after my stint in the penal colony) would be smooth and easy. Not to be.

In Australia, a great deal of pride is associated with our lack of class-system. There is no aristocracy, no hierarchy and in particular, no elevation of doctors above the general population. As such, it is considered wanky to brag about being in medicine. We do it, but we know it's wanky.

Due to this lack of pretension, I have learned that when I communicate with my superiors by email, I should address them by their Christian name, and use polite but informal language.

Not so in Canada. In explaining my tardy reply to the head of U of T's family medicine residency, I addressed him by his first name (with which he had signed his initial email), used informal language and signed off with a sincere "Cheers".

His response was quick, scathing and signed "Doctor ....."

My knee-jerk response was "Wank"! It'll take some time to re-acclimatize.

In any case, given the massive disaster unfolding in Japan (and on the heels of the disasters in Christchurch & Queensland) it all seems trivial. I keep reading Dad's SAS survival manual and thinking about what I can do to help.

The Civil Defence Service has some suggestions:

In no particular order...

Things I will miss in Melbourne:
- pies
- good coffee (served with a sneer)
- blue skies and bright sun
- red Bonds undies peeking out of low-riding boy jeans
- thongs for all occasions
- Vic Market Sundays
- dumplings & yum cha
- The Age & The Herald-Sun (quiz only)
- running Princes Park
- "cold" oceans of 18-20 degrees C
- the melodious sound of Kiwi accents
- Indian take-away in Ringwood
- macaroons in GPO
- early Saturday texts from D saying "Brunch?"
- "quiet night out" this Friday
- soccer girls (both lemons & kiwis)
- rural rotation sleepovers & country races
- daily sun-block
- "Cheers, big ears!"
- housemate Masterchef
- my bed
- "You'll be right, love"
- cousins!
- cups of tea & scones
- Registrars & Interns, ressies & foxtel, proper specialty training, Nurse Bear on call
- Carlton Draught, on tap
- morning & afternoon tea
- Ti Amo with E & Z
- love-song dedications with Richard Mercer
- Target Country, utes, blundstones and Bonds singlets
- You.

Thanks for the best 6 years of my life.

Breaking news (3 days late)

Breaking my blog moratorium to share this important news:

9 artists are making a 30 second video every day for the month of February.

Geoffrey James is one of those artists. He is very good. I am also enjoying the films by Aaron.

It's a daily treat to remind one that, no matter how uncertain the future, you can always enjoy the sight of a man being hit with a Swiss ball.

www.vcam2.com

Good times.

Me & Bobby McGee

Sitting in LAX with a film of fatigue & sweat coating my skin, I feel strangely at peace.

Perhaps it was the All Blacks doing the safety demonstration on my flight. Perhaps it's the way the barista didn't sneer at my request for a skinny latte (in Melbourne, this is a deportable offence; skinny milk doesn't enhance the roast correctly). Perhaps my 30-hour stench is warding off stress and ennui. It's certainly cleared me a space at the departure lounge.

My intern year is done. I am a fully accredited, licensed doctor.

I have absolutely no idea where this year will take me. I've got plans for every continent. Jobs in every hemisphere. Reefs to dive, sun to catch, canals to skate, exams to write.

For the first time in 5 years, I have no idea where I'll be in 6 months. It's so exciting that I almost don't need a third latte. Then again, I'm turning 30, unemployed and contemplating moving into my parent's basement. Extra strong, please.

I owe a massive thank you to Ian who made an "airports and trips home" mix a few months back. I'm spending the next three weeks with it on permanent rotation. Decisions will be made with an excellent soundtrack.

And to my regular readers, thank you for following me all through the year; I'm out until I've got another job (doctor or dive instructor, either one) or until I move to Christchurch.

Kia Ora!

goodnight and good luck

Dear Cardiothoracics,

As we enter our last week together, I can't help feeling bittersweet about the last 3 months.

You, frankly, were awful to me. You took my sleep, my social life, my self-esteem and my ass (no food = no booty). You broke me down to almost nothing. I dreamt about you, horrible nightmares where people never stopped bleeding. I would wake up gasping, then count down the days until I was free.

But now that I'm almost there, I find that I'm not ready to leave. Perhaps I've been institutionalised. Perhaps it's the Stockholm syndrome talking. Or perhaps I can see that while you may have been the breaking of me, you have also been the making. Cos I can handle you.

I can work these hours. I can manage these patients. I can stitch these wounds. I can put in these chest tubes. I can run with the alpha males and keep up. I can do this.

(You have also messed with my head in serious ways; I'm pretty sure my desire to stay means there's a disturbing masochistic streak in me. My boss verbally abused me the other day and I thanked him. He laughed, "Hit me again, sir". Creepy.)

Still, at the end, I must thank you. If I can survive you, I can survive anything. Which means I have unlimited options for the future.

What are these plans? I don't know. I have 4.5 more days with you, then the world is my oyster.

So, thank you for all that you've done for me. Best of luck with your future endeavours (growing grafts in test tubes! endoscopic vein harvests!). Perhaps we'll run into each other in a hospital in Canada. I'd like that.

All the best. Truly.

Sam