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.