Currency of surgical placements / Medic diaries No.3

8 March 2014

On Thursday I started my ophthalmology placement. I am based in a rather small district hospital and my placement mostly involves sitting in eye clinics and learning about eye examinations and diseases.

 I will also have to go to theatre 3 times during the next two weeks to observe eye surgery (which I'm dreading, it gives me chills to even think about someone poking an eye with a knife). Patients are usually awake for this as it's sufficient to anaesthetise the eye and eye muscles to operate. I'm also going to observe cataract surgery and lacrimal duct surgery (tear duct leading from eye to nose ) for which I need to revise some anatomy.

Surgical placements follow a certain pattern. Knowledge is your currency. If you come in to hospital early you have a chance to talk to the patient before the surgeons do. You know the patient's case and can present on the ward round if your patient is an in-patient, i.e. stays in hospital before the operation. If it's just a day case surgery you still want to know the patient as it looks good when you can say that to the surgeon (S: have you met this patient before? M: oh yes, I've spoken to him this morning (*in a casual tone*). *impressed eyebrow raise from the surgeon*.)

Usually before surgery surgeons review scans and lab results. If you're there as a student you can expect to be quizzed on the anatomy, on pathophysiology of the disease and if you show enthusiasm and interest even on the surgical approach to the problem. Gaining brownie points in those exercises usually will lead to the surgeon saying : "Do you want to scrub in?" and then " have you scrubbed in before or do you want one of the nurses to help you?". If your answer is a confident yes to both, you make the surgeon happy. But this only happens once you've traded in your knowledge earlier on.

Unfortunately my med school is not the best at teaching anatomy. We did quite a lot of dissection of the chest and abdomen (yes it means what you think it does. small group work. I still have my dissection kit in a cupboard) but strangely we never did the head or limbs. So tomorrow I'll be trying to make sense of the eye anatomy using the Internet.

I've been thinking a lot about the qualities that one needs to have to be a good doctor. This is one of the most commonly asked questions at medical school interviews. Usually my answer involved qualities such as being knowledgeable and competent, being dedicated, a good communicator and a people's person, being decisive, compassionate, interested in patients and caring. Ability to synthesize information from the available sources and making sense of it is important too as well as being able to cope with uncertainty and take responsibility for one's actions. What has never occurred to me before is that confidence is an important quality too, and one I will have to work on probably the most in the next year before I qualify. Patients are scared when they're feeling unwell. They want their doctor to come across as confident, to perform the examination in a confident manner, to speak with confidence about the next steps that are going to be taken to make them feel better.

All of the doctors I'm learning from are great at that and I, as a student. am struggling. I am good at examining patients, I've practised with my friends and with J, rehearsed every step, passed my OSCEs* but I still think it's a nuisance to patients because I'm just a student. On top of that confidence doesn't come to me naturally. I'm usually happier as a follower not a leader. But I know it's yet another skill I have to practise to be a good doctor. And yet another thing I wish I knew was expected of me before I applied to medical school.

What do you expect your doctor to be like? Any tips on how to be more confident but not overconfident? 

*OSCEs stand for Objective Standardized Clinical Examinations i.e. practical exams which medical students have to pass each year. They usually last between 5-10 min per station with about 5-20 stations per exam, with a scenario and a patient to take a history from and examine at each station. The aim of the exam is to make sure that students are competent at clinical skills under time constraints. You have 1 minute to read the instructions before entering the examination room, 5-10 min to perform the exam, give a diagnosis and management plan, answer exterminator's questions. Then the whistle goes off and you move on to another station.

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