Learning objectives are the foundation of every university course. Objectives are written based on a needs assessment that has determined what students should learn in a course. To be effective, these objectives must be specific and measurable. All teaching and course evaluation should be based around these objectives. This means that students will always know exactly what is expected of them, lecturers will remain focused on these areas, and there will be no surprises on exams. Or at least that is how it all should work.
Unfortunately, many medical students find learning objectives unwieldy and unappealing. Students are often presented with vague statements about a broad topic to be covered which gives them insufficient direction for their studies. Sometimes lecturers who are given learning objectives do not actually lecture on the intended topic areas, leaving students with repetitive or confusing information.
So what exactly do effective learning objectives look like? They should specify exactly what students will know or be able to do upon completion of the learning. Instead of typical overviews such as
“This course will introduce you to opioid and non-opioid analgesics”
An example of a more appropriate learning objectives should be:
“Upon completion of this course, students will be able to describe the mechanism of action of NSAIDs as analgesics.”
The key aspect here is that it specifies exactly what the students will be capable of. This type of specific objective also makes it absolutely clear to us as students what we need to be able to do for examination purposes.
Learning objectives also need to be genuine. They should be followed by teaching and evaluation. Medicine is constantly evolving and our courses should reflect thisIf students do not trust that the learning objectives truly cover everything that they are expected to know, then all learning objectives become of little use.
When used properly, learning objectives are wonderful things. Any lecturer who has ever needed to answer the question of whether something will be on an exam should embrace learning objectives. These learning objectives also make independent study and seeking out other sources of information more straightforward for students. With specific, measurable, and genuine learning objectives, everyone wins.
As much as the truth hurts, I don’t think I am particularly handsome, nor do I consider myself particularly unattractive either. It’s a happy medium. Nevertheless, when you sit next to someone in class like my handsome friend Brad, you can’t help but feel a little insecure about yourself. The world just seems to favour these attractive people – whether it is job offers, achievements and success, or competing for a girl. Some of you might share my feelings; some of you may disagree. Yet a question still remains: are beautiful people lucky?
Unfortunately, this is true – at least so far as social psychology findings suggest. Studies have found that physically attractive people are often judged in a more positive light than less attractive individuals, in terms of perception of academic success, achievement-related traits and intelligence. [1] Moreover, it turns out they also have better job suitability ratings (irrespective of job type), higher starting salaries, higher voter ratings when running for public office, and they also receive more favourable judgements in trials. [2]
Unfair and preposterous, you might say; it seems that they can get away with anything. Well not exactly, as beauty can be a disadvantage, especially for attractive women, applying for ‘masculine jobs’ where physical appearance is perceived as unimportant. [2]
Where do all these judgements and bias come from? We often make judgement of others based on a few central characteristics. [3] Physical appearance is conveniently one of the first things we notice and from this limited information, we make inferences about associated attributes, such as academic-related traits and success. Such a response creates a stereotypical construct of the person, on whom we apply a set of judgements that befit the person’s prototype. [1] Positive characteristics prime positive inferences and vice-versa.
So how does gender play a role in our initial judgements of people? A recent randomised controlled trial study supports that gender is a key factor in our inferences about others. [4] People tend to favour and glorify the attractive member of the opposite sex with positive attributes, while depreciating those who are attractive but of the same sex. That is, a man would tend to judge another attractive man in a negative light, meanwhile, venerate an attractive woman. [4] The study postulates an evolutionary basis for this social phenomenon, driven by our instinctive desire to mate; with the suggestion that attractiveness may reflect health and reproductive capacity. By devaluing attractive same sex competitors, we might in turn strengthen our position in the game of mating. And by glorifying the attractive member of the opposite sex, we make that attractive individual even more attractive by attributing high qualities to him or her. The combination of these two processes may serve to improve our chance for the best pair bonding.
It seems that without even knowing it, I was participating in the process of the mating selection with my friend Brad. Next time you find yourself developing a negative impression of an attractive person of the same sex without good reasons, it could be your mating instinct staking its claim.
References
1. Chia, R.C., et al., Effects of attractiveness and gender on the perception of achievement-related variables. J Soc Psychol, 1998. 138(4): p. 471-7.
2. Johnson, S.K., et al., Physical attractiveness biases in ratings of employment suitability: tracking down the “beauty is beastly” effect. J Soc Psychol, 2010. 150(3): p. 301-18.
3. Schneider, D.J., Implicit personality theory: a vreview. Psychol Bull, 1973. 79(5): p. 294-309.
4. Forsterling, F., S. Preikschas, and M. Agthe, Ability, luck, and looks: an evolutionary look at achievement ascriptions and the sexual attribution bias. J Pers Soc Psychol, 2007. 92(5): p. 775-88.
So you know all the manifestations of Marfan syndrome and have your head around Osler nodes and Janeway lesions, but have you ever heard of Tashima syndrome? Self-named in 1965, the condition is one in which a doctor seeks a “new sign, disease, or syndrome to which his name can be attached.”[1]
Such disease names are called eponyms and their use in medicine is extremely widespread. Eponyms may take the name of a discovering doctor (Parkinson’s disease), literary reference (Alice in Wonderland syndrome), mythological figure (Ondine’s curse) or, rarely, a patient (Lou Gehrig disease). [2] Eponymous disease names have always been a part of modern medicine however, their continued use is an area of considerable controversy.
Multiple arguments against eponyms in medicine have been made. The use of eponyms can be confusing as the terms used are not always descriptive or consistent. There are some diseases that bear multiple names, some names that refer to multiple diseases and even some diseases which have different names in different countries! Furthermore, inconsistencies between the use of possessive (Down’s syndrome) and non-possessive forms (Down syndrome) of disease names can lead to difficulty in locating information in literature searches. [3]
Traditionally a disease is named after the person first describing it, but this is not always the case. For example, Benediktos Adamantiades described the constellation of genital ulceration and uveitis seven years before Beçhet described this disease which would bear his name. [4,5] Many other examples of such misattribution exist and are used as an argument against eponyms. There is also controversy about the use of eponyms named after somebody who engaged in unethical behaviour. A well-known example of this is reactive arthritis, or Reiter’s syndrome. Exposure of Hans Reiter’s strong involvement in the Nazi party during World War II has led to calls for the term “reactive arthritis” to replace “Reiter syndrome”. [6,7] Reflecting this shift in the medical community, the use of the eponym “Reiter syndrome” in the literature has recently fallen out of favour. [8]
Eponymous names do, however, also have merits. For those conditions or syndromes which are a constellation of symptoms, eponyms can provide a brief phrase to encompass that disease. For example, Tetralogy of Fallot is a simple way of describing this complex cardiac defect. Practicalities aside, the use of eponyms appeals to those who, like me, are a little bit nostalgic. Eponyms provide a link to those practitioners who shaped the profession we are soon to join. They encourage us to remember their mistakes as well as their successes and serve as a reminder that despite all the science, the practice of medicine remains an art.
Whilst it would be impractical to rid medicine of all eponyms, the agreement by major international bodies on the best term, or “orthonym” [9] for a disease may reduce some of the confusion. It is also clear that some eponyms will disappear as our understanding of eponymous conditions improves. For example as our understanding of kidney disease has developed, the term “Bright’s disease” which encompassed several forms of glomerulonephritis has fallen out of use. To a certain extent, whether these terms continue to be used will be shaped by the choices we make as future medical professionals and the culture that develops. This is why, as the debate continues, it’s worth tuning in and taking part.
What do you think?
References
1. Tashima CK. Tashima’s syndrome. JAMA : the journal of the American Medical Association 1965;194(6):678.
2. Taylor RB. Whose Syndrome? Stories of Medical Eponyms. In: White Coat Tales: Medicine’s Heroes, Heritage, and Misadventures: Springer; 2007. p. 87-102.
3. Jana N, Barik S, Arora N. Current use of medical eponyms–a need for global uniformity in scientific publications. BMC medical research methodology 2009;9:18.
4. Woywodt A, Matteson E. Should eponyms be abandoned? Yes. BMJ 2007;335(7617):424-.
5. Zouboulis CC. Benediktos Adamantiades and his forgotten contributions to medicine. European journal of dermatology : EJD 2002;12(5):471-4.
6. Panush RS, Wallace DJ, Dorff RE, Engleman EP. Retraction of the suggestion to use the term “Reiter’s syndrome” sixty-five years later: the legacy of Reiter, a war criminal, should not be eponymic honor but rather condemnation. Arthritis and rheumatism 2007;56(2):693-4.
7. Wallace DJ, Weisman M. Should a war criminal be rewarded with eponymous distinction?: the double life of hans reiter (1881-1969). Journal of clinical rheumatology : practical reports on rheumatic & musculoskeletal diseases 2000;6(1):49-54.
8. Lu DW, Katz KA. Declining use of the eponym “Reiter’s syndrome” in the medical literature, 1998-2003. Journal of the American Academy of Dermatology 2005;53(4):720-3.
9. Turnpenny P, Smith R. Of eponyms, acronyms and…orthonyms. Nature reviews. Genetics 2003;4(2):152-6.
It was Friday afternoon of the first week of my rural term. I was in a town of approximately 4000 people, located over 500 kilometres away from any metropolitan centre. We had seen the last booked patient for the day and the outpatient VMO had left to make an early start on his weekend. As I walked across the hospital driveway, the pleasant silence was suddenly interrupted. Sirens blazing and engine roaring, an ambulance sped down the road and pulled into the hospital. With a rush of excitement, I made a move for the emergency department.
In the ED, a nurse gathered a resuscitation trolley while talking on the phone. Two heavily built ambulance officers stormed through the back door, wheeling an unconscious man on their trolley. He had a suspected ruptured abdominal aortic aneurysm requiring immediate surgical attention. Before I knew it, I had a gown and gloves on and was counting compressions. As I counted, people streamed in. A doctor was at the head of the patient measuring a Guedel airway. Almost immediately, the patient started vomiting. The Guedel was yanked out and a suction tube was shoved down his throat.
Drama after drama ensued. Countless attempts were made to insert an IV line; followed by an attempted intraosseous line that never happened due to broken equipment. After another five attempts, one nurse was able to get an IV in. Airway support proved equally challenging. The patient aspirated his own red wine vomitus. Two GP registrars attempted to intubate the patient but struggled to get through all the vomitus. Following an hour of torment, and despite the efforts of numerous medical staff, the patient passed away. Just as suddenly as it had started, it was all over.
For weeks afterwards, my mind was filled with uncertainty. Did we do everything we could for this man? Are rural hospitals properly equipped for such catastrophic events? Does medical school prepare us for these emergencies? In the end it was all irrelevant. Even if we had managed to get an airway in straight away, even if adrenaline had been administered immediately, it would have made little difference. What this man really needed was a vascular surgeon, and the nearest one was at least three hours away.
As a medical student, it was very difficult coming to terms with such an event. I hazard to say that many of us are poorly equipped to deal with matters of death and dying, particularly when it is unexpected or occurs in younger patients. Although some medical schools provide courses for coping with death, there is limited evidence about how they should be run or if they are even beneficial. Such classes are impeded by an already overloaded medical curriculum, and a potential lack of perceived importance by untested students.
This experience made me realise that, although people may teach you about dealing with death, such as Kubler-Ross’ five stages of grief, it is always unique and different when you experience it. From my own experience, and that of my peers, being in a rural placement can be especially challenging. This stems from a combination of isolation, delayed counselling and support services, potential frustration at the limitations of rural hospitals, and the lack of nearby friends and family. Whilst at times, there was nothing I would rather than to avoid dealing with it, I have found that it is not only worthwhile, but essential, to reflect and reach out to others, in order to better understand our own emotions and inner conflicts.
“Our own death is indeed unimaginable… At bottom no-one believes in his own death, or to put the same thing in another way, in the unconscious every one of us is convinced of his own immortality”
Recently, I was given the opportunity to present at the Paramedics Australasia Regional Queensland (PARQ) Conference. It was an honour, however, I was only able to create my presentation through seeking help and information from many of my professional contacts, to fill gaps in my knowledge on the presentation topic. In instances like this and on many other occasions, I have found that professional networking has been tremendously helpful.
Whilst many medical students recognise the value of having professional contacts, it is often unclear how to go about it and whether they should bother at all. I can assure you that even as a medical student, it is possible to make helpful and interesting contacts through networking. I have listed below a few of my tips for beginners that will help you meet people in the right situation and make a good impression.
1. Attend conferences
This may be an obvious one, but if you have not attended a conference before then you might not realise how incredible they are for building professional contacts. At conferences, you can meet many people with similar interests, including well-respected people in your field (who probably would have ignored your emails if you tried to get in contact with them through that way!). This face time can be a vital first step. Planning can go a long way and it can even be a good idea to have specific people in mind that you want to try to meet at the conference. For all of this to work, the standard rules for making a good first impression in a professional setting must be followed: Firstly, dress appropriately for the conference (if unsure, it is probably better to overdress than underdress), be confident in your initial approach, conscious of your body language and finally, ensure that you have a firm handshake.
2. Have business cards ready
It may sound like overkill, but it may be helpful in providing contact information whilst also demonstrating your professionalism. You can have simple, professional looking business cards made online at a relatively low cost. The business cards do not need to be fancy and only require your name and contact information. The main use as a student will be to exchange them with someone who you meet at a conference. It is also wise to keep some with you at all times as you never know when you may have an opportunity to meet a future professional contact. It will certainly leave a lasting impression when you, still as a student, can exchange business cards rather than simply taking theirs.
3. Build a professional Internet presence
As a medical student, you have probably already considered your presence on the Internet and what results appear when you Google search your name. However, for many medical students, this starts and ends with locking down your Facebook privacy settings so nothing can be seen publicly. Building a professional presence on the Internet should go far beyond this. As a medical student, it is not too early to set up a profile on the professional social networking site LinkedIn. It may also be helpful to set up a resume-based web page using a service such as re.vu. This way, the first hit when you search your name on Google will not be your locked down Facebook page, but instead will be a brief page about your professional background that includes your contact information.
There is much more to building a professional network than these three basic tips, but following them will set you on the path to success. Start building your professional contacts while in medical school and you are likely to find that this small investment now will pay huge dividends in the future.
As an avid coffee drinker, I was delighted by the recent article published in the New England Journal of Medicine which concluded that coffee consumption was inversely associated with mortality. [1] Coffee is the most widely consumed non-nutritive food item in the world, available in virtually every country. As such, it has been the subject of intense nutritional research to validate positive and negative health claims. For decades it was thought that coffee consumption in excess of two to three cups per day was detrimental to health. For example, in a study published in 1986, 1130 male medical students were followed over 35 years, and those who consumed five or more cups of coffee per day were 2.5-fold more likely to develop cardiovascular disease. [2]
However, there has always been controversy about the validity of the apparent detrimental effects. In a follow-up study conducted on 51 000 health care professionals in the US, it was concluded that coffee consumption did not significantly increase the risk of cardiovascular event or stroke. [3] After years of inconclusive and conflicting data, the recent study which included 229,119 men and 173,141 women (50 to 71 years of age) in the US National Institutes of Health–AARP Diet and Health Study, clearly demonstrated inverse associations for deaths due to heart disease, respiratory disease, stroke, injuries and accidents, diabetes and infections. [1] Interestingly, the hazard ratios for death (all-cause) amongst coffee drinkers versus non-drinkers decreased in a dose-dependent manner (0.99 for 1 cup/d to 0.85 for 4-5 cups/d). [1] Unfortunately for those of us who tend to drink six or more cups a day, the hazard ratio begins to increase again and the apparent benefits begin to disappear!
So are we in the clear? Should we up our coffee intake to five cups per day for maximum effect? The short answer is no. This study was conducted in the US and failed to account for coffee preparation methods. In North America the main coffee preparation method is drip-brew with paper filtration. Unfiltered coffee and mesh-filtered coffee (French press and European style), which are popular in Australia, tend to have high levels of cafestol and kahweol which are diterpene compounds found in the lipid fraction of coffee grounds. [4-5] These compounds appear to promote (in addition to a delicious flavour) increased plasma concentration of cholesterol. Importantly, these coffee-borne lipids have been suggested to be the source of the detrimental health associations with increased coffee consumption. [4] The paper filtration method traps these lipid compounds, preventing their consumption. It appears that the decrease in mortality may only extend to paper filtered coffee, which I have discovered is unpopular in the coffee-loving city of Melbourne. There are numerous antioxidant compounds in coffee which may attribute to the potential benefits of moderate consumption. However, as with all of life’s indulgences, moderation still appears to be the key.
[1] Freedman ND. Association of Coffee with Total and Cause-Specific Mortality. N Engl J Med 2012; 366:1891-1904
[2] La Croix AZ. Coffee Consumption and the incidence of coronary heart disease. N Engl J Med 1986; 315:977–82
[3] Grobbee DE. Coffee, caffeine, and cardiovascular disease in men. N Engl J Med 1990; 323:1026-1032
[4] Ranheim T. Coffee consumption and human health–beneficial or detrimental?–Mechanisms for effects of coffee consumption on different risk factors for cardiovascular disease and type 2 diabetes mellitus. Mol Nutri and Food Res 2005; 49(3):274-294
[5] Ricketts ML. The cholesterol-raising factor from coffee beans, cafestol, as an agonist ligand for the farnesoid and pregnane X receptors. Mol Endocrinol 2007; 21:1603-1616
When the journey to becoming a consultant takes at least ten years, it’s understandable that most students are eager to clamber to the top of the ladder as quickly as possible. Consequently, the thought of taking at least another three years away from medicine to do a PhD is far from enticing (unless you intend on a career in medical research or academia).
What’s the benefit then, in undertaking a PhD if you still intend on a career in clinical medicine? Is there a need for medically trained clinicians to undertake the rigorous training of a scientific researcher?
When I completed my Honours research project halfway into my medical degree, I fell in love with it enough to defer my degree and complete a PhD. I watched my fellow medical students graduate and begin working as ‘real doctors’ whilst I pottered around the lab growing colon crypts in a test tube and analysing human tissue samples on an intricate and temperamental instrument known as the Mass Spectrometer.
This scenario is rare but becoming less so in Australia, with more and more students taking the so-called ‘MD-PhD’ training route which is a formalised combined degree in the United States. Alternatively, those who seek to be a Dr-Dr can also undertake a PhD after entry into specialist training. Ultimately, this blog aims to address two questions: 1) Is a PhD worth it? 2) When is the best time to do it?
1) Is a PhD worth it?
There is no doubt that undertaking a PhD is beneficial, but it’s not for everyone. A PhD equips you with the skills of being a fully-fledged independent researcher; you get to design your own project, establish new methods, present and publish results, and (if you’re lucky) write your own ethics applications and grants. The experience of making completely novel discoveries and publishing them is incredibly rewarding, and the entire PhD experience challenges you to think in a way that is completely different to clinical medicine. Having a PhD is also in some ways a ‘golden ticket’ that will give you a step ahead into many highly competitive specialities, or will help you secure a job in large metropolitan tertiary hospitals. It also opens many career doors by giving you options to vary your workload to include a combination of clinical work, research and teaching. Having said that, a PhD is also three years out of your life with very little pay, and for those who don’t desire a career involving research to any extent (e.g. if you want to be a garden-variety GP) then doing a PhD in molecular biology is probably not going to help your career enormously…
2) When is the best time to do it?
Doing a PhD early (e.g. prior to completing the MBBS) is easier financially as you are less likely to have a mortgage and three screaming kids to feed. It also gives you more time to build your research portfolio and having the PhD will help you in getting to the specialty you want. On the other hand, doing a PhD later (after specialising) means that you can be certain the topic of your PhD is in your area of specialty, and you are qualified to work in clinical medicine whilst PhD-ing. Like all good debating topics, there is no correct answer, and this depends very much on personal circumstances.
If you are interested in a PhD, speak to one of the conjoint clinician-academics at your medical school as they most likely would have completed one at some point in their career.
My experience:
The thought process I went through in deciding to defer medicine to undertake a PhD halfway through the degree was not an easy one; I was doing well in medicine and also had a lot of friends (many from high school) going through with me in the course. At the same time, I was tempted by the fact I had a great relationship with my research supervisor, and had started working on a project I truly loved and was well-familiar with the literature (all advantages for going into a PhD). Ultimately I made up my mind after talking to many faculty and hospital staff members, discussing with family and weighing up the pros vs cons.
Although there were periods during the PhD that were difficult (all research is unpredictable) coming out of the PhD I have no regrets in undertaking this detour. Going back into clinical medicine has been surprisingly much easier than I originally thought it would be. Although lacking somewhat in clinical knowledge (which comes back fairly quickly with study and practice) I have gained a whole suite of written and oral communication, teamwork and self-directed learning skills from the PhD which have been really handy in the wards in ways that are difficult to put down on paper.
My future ambitions are to be a clinician-researcher. However, anyone with an interest in academia or is contemplating a specialty that requires some research understanding should consider a PhD at some point in their training.
I’m sure there are many of you who are wondering what being an intern in a modern-day Australian hospital is like. Over the next few weeks, I will be writing about some of the things that happened during my first year on the job.
The First Day – “Your job is to push the trolley”
I’ve lived through over 1,200 Mondays, but the first day of internship was the first I have ever looked forward to.
What exactly does an intern do? One intern suggested to his consultant on a ward round that his patient was anaemic, probably due to folate deficiency. The consultant replied ‘your job is to push the trolley.’
First, let me say, I much prefer being an intern to a final year student. This is despite the fact that the majority of time spent as an intern is doing thankless tasks…including pushing the trolley. For example, “get a CTPA for this patient” asked the consultant. It took two seconds to ask, but nearly two hours to organise. And it will take two minutes to view the results and chart the appropriate dose of enoxaparin. Still, if you didn’t put in those two hours, the patient might deteriorate.
The nurses bombard you with tasks: charting fluids, replacing cannulas, writing discharge letters, and clarifying medications. This is in between the patients who need medical review for hyperglycemia, hypotension, chest pain, broken nails and everything in between. The to-do list grows until the evening shift begins, then it quietens down and you can concentrate on tying up the loose ends so the even busier after-hours intern doesn’t trip over them. All the while, however, you are making a difference to patient care, and knowing that you’re contributing is a great feeling.
The most time I spent with a patient today was during a cannula insertion. What I missed the most was the patient contact time. It’s not that I didn’t want to be around them, they have interesting histories to share and a need for therapeutic listening from their doctor. There just isn’t time during your shift, and it would take an extraordinary person to stay back well after their shift ended to spend time with their patients and ignore the rumbling in their stomach or the numbness in their mind. Again, it’s not for not wanting to, but after a certain time of non-stop activity, your brain demands you to retreat home, where you know you can let the world spin for a while.
When you walk out the hospital door into the setting sun – if you’re lucky – or the night if you’re not, it feels good. Because no matter how unglamorous, tedious or repetitive the tasks, by doing them you are one step closer to sending your patients home. Your patients, for the most part, are sincerely grateful for your hard work and appreciate whatever little time you spend with them. There’s no better way to help people or improve their quality of life than to get them out of the hospital – as long as you don’t think the same thing about yourself.
The intern is a facilitator, an organiser, a checker and a doctor. They are the link between the nursing and the medical teams. It’s a challenging job, busy too (unless you are doing urology), but you have responsibility, and at the end of every day, you have achieved something, even if you feel like you haven’t.
I’ve enjoyed it so far, I still look surprised when someone addresses me as ‘doctor,’ I still can’t believe my bank account has grown by $4,000 in a month and I am hoping the novelty doesn’t wear off soon.
Watch this space:
Part 2: Australia Day – “The Whiteboard Always Wins”
Part 3: A night in aged care – “that’s not the doctor, that’s my son”
4 years ago, when I was a young, naive 18 year old leaving home for the first time, in a conversation with another young, slightly more naïve but pretty 18 year old:
…so yeah I’m off to study medicine in Tasmania.
‘Oh really? Wow that’s so noble of you!’
[Feeling pretty confused] umm…sorry?
‘That’s pretty impressive that you’re going all the way to Africa to study medicine! Aren’t you worried about the wars and AIDS?’
[Realizing that she was talking about Tanzania, which by the way has no war as far as I know] oh…yeah. [Pause] I guess I am pretty impressive.
I thought it’d just be easier if she thought I was risking my life saving lives in a war-torn country rather than explain the full story. She was very pretty.
International students form an important part of the medical student landscape in Australia. In 2009, we had about 3400 new medical students out of which roughly 15% were international medical students (1). It is a privilege for Australia’s medical workforce to be such a multicultural one which attracts students from all across the world with a variety of backgrounds, and I’m glad that I’ve been fortunate enough to be a small part of the excellent environment here. The past four years have been nothing short of amazing for me and personally I’m enjoying every single day here.
Having said that, I haven’t forgotten the very real difficulties I faced initially in a new environment. The first year in particular was very difficult for me, trying to settle into a foreign environment coming from a distinctly different background as I did. Whilst many international students took to Australia like a fish to water, I know I would have appreciated some advice before coming here. So here’s some quick advice on medicine and life in a new country that I’ve learnt the hard way in the last 4 years:
Do your research and know what you’re getting yourself into.
This applies to basically everything, be it the choice of medical schools or the place of residence. I remember my first weekend in Australia was spent at MedCamp after a 5th year student explained that it was a good chance for me to practice ‘medical skills’. I spent the weekend terrified in the corner watching others drink ridiculous amounts of alcohol and saw more censored content than I ever have in my urology or breast surgery rotations. And to those really cool kids that run these camps – if you see a poor kid sleeping by himself in the corner, don’t throw ketchup or milk or eggs at him. Or have sex in his bunk without inviting him. That’s just poor manners really. In all seriousness, it pays to do your research before committing yourself – for example if you love the outdoors Tasmania can be a perfect location for you, whereas if you may want to consider somewhere else if shopping is an essential part of your existence.
Look confident.
I know this is one that all medical students struggle with, but it becomes much harder when you come from a radically different background. It took me ages before I could stop stuttering when consultants asked me a question during ward rounds. Often I find that the problem isn’t actually knowing the answer, but answering in a coherent manner. The only solution is to practice, practice and practice again. Particularly for those whom English may not be their first language, it becomes even more important not to run away and to confront the problem by spending time on it. There’s no shortcut, but it’s undoubtedly one of the most important aspects of clinical practice.
Spend time with patients.
I’ve often found a lot of joy interacting with patients – most of them are highly approachable and are interested to talk to people from different backgrounds. The most bizarre conversation I had was with the father of a paediatric patient whose second sentence to me was ‘I’m a racist’. By the end of the conversation he was confiding in me about his sister-in-law who was on the run from the law for a stabbing. I’ve been fortunate enough to meet so many patients who have treated me with such kindness and openness, and they’ve taught me more than any textbook can teach me on practicing medicine. So hit the wards and get to know your patients. You never know what amazing stories they have in store for you.
Put yourself out there.
Most people I’ve met have been incredibly kind and generous to me. The best illustration is probably my time on rural placement in Flinders Island – the community was extremely receptive to us and the 2 weeks I spent there were the best ever in my medical school. We had a great time in terms of learning medicine, but on top of that we went rockclimbing, spearfishing, lawn bowling, bushwalking with a group of 70 year olds and Scottish dancing with a lady over 90 years old. There are so many experiences awaiting you just around the corner – so get out of your comfort zone and choose your own adventure.
Be open minded
When living in another country with a radically different set of values and traditions from yourself, it can be easy to be judgmental and compare it against your own culture. Be it in medicine or in general life, it’s always important to be open and accepting of people that are radically different from you.
Maintain a work-life balance
It’s easy to be overwhelmed by the extent of medicine and spend days buried in books and lecture notes. Don’t. Get out there and live your life to the fullest– be it volunteering, sports, part-time work or a night out with friends. I’ve been incredibly fortunate to make some like-minded friends and I now often spend my weekend rockclimbing or bushwalking. Working with the Big Issue’s Street Soccer Program was also an amazing opportunity for me – I met so many players from all walks of life and they gave me the hardest thing to gain in life: perspective. I do believe that all these experiences have made me grow up and a better student doctor in the end. So go out there and experience life – medicine is so much more than facts and figures.
Having said all of that I must emphasize that my time here has been thoroughly enjoyable. It wasn’t always easy, and there were moments where I doubted my decision to come to the land Down Under all alone, but looking back I know I made the right choice. My friends here have embraced me in a way that I’d never thought possible and I’ve shared with them experiences I’ll remember for the rest of my life. So there you go – get on that plane and enjoy some of the best years of your life.
Foong Yi Chao is a 4th year medical student studying medicine in Launceston General Hospital, Launceston, Tasmania, Africa. He spends his days dodging bullets and saving lives.
1. Medical Deans Australia and New Zealand. National Clinical Training Review: Report to the Medical Training Review Panel Clinical Training Sub-committee [Online]. 2009.
Malawi is known as ‘the warm heart of Africa’ and even has a ‘Miss Warm Heart of Africa’ competition (not open to Australian entrants). I spent eight weeks there last year, working in a rural hospital, and found it certainly lived up to its reputation for hospitality and friendliness.
Malawi is one of the poorest countries in the world (life expectancy is 44 for men and 51 for women), and the hospital at which I was working was facing some major challenges. HIV, TB and malaria were rife, and treatment options were limited or non-existent. I had read lots of articles about healthcare in Malawi before I left, and I thought I was reasonably prepared. I was wrong…
WEEK ONE: THE DANGEROUS DRUGS CABINET
On my first day, I open the cabinet marked ‘dangerous drugs’. And find Omo. Apparently the drugs ran out a while ago, and the Omo kept going missing, so now there is a lockable Omo Cabinet. But still no drugs.
WEEK TWO: WE RUN OUT OF DIAZEPAM.
Week two and I’m on the paeds ward, surrounded by very young children with malaria, pneumonia, sickle cell anaemia and HIV/AIDS. It’s mostly the kids who die of malaria here, although virtually every patient has it. A baby with cerebral malaria starts convulsing. The hospital protocol (helpfully displayed on the wall) calls for diazepam and a paediatric airway. I don’t have either; in fact, I don’t have anything. The baby dies. I confirm her death, explain it to the large extended family crowding round the bed watching me (one of the nurses interprets for me as I can’t speak Tumbuka), and start dressing her in the little pink dress that is the only outfit she owns. She is wrapped up and placed on her mum’s back to be carried home.
WEEK THREE: WE RUN OUT OF FUEL.
I spend week three in the male ward, where a slightly unorthodox approach to patient confidentiality is adopted. Rectal exams are carried out in full view of the other patients; ward rounds involve a nurse pointing to each patient in turn and announcing “this one – his scrotum is swollen”.
The hospital has bigger problems than the odd swollen scrotum however: there’s no fuel. There’s a national shortage in Malawi, which means obtaining hospital supplies like gloves, syringes and drugs is next to impossible. Mobile health clinics in surrounding villages have to be abandoned, and the ambulance is useless.
WEEK FOUR: NO FUEL MEANS NO POWER.
Malawi is plagued by power blackouts. During my stay, there was a blackout lasting from a few hours to a few days almost every day. There was never any power on Sundays.
The hospital had a generator, but for my first few weeks it wasn’t working. Then it was working (thanks to a roving engineer from Scotland who happened to drop in), but it needed diesel. There wasn’t any.
Without power, surgery was completed by the light of handheld torches, headlamps and mobile phones. Several patients on supplemental oxygen died during blackouts; one baby died when the lights went out during an emergency c-section and he was overlooked in the ensuing confusion.
WEEK FIVE: WE RUN OUT OF GLOVES.
I’m in the maternity ward now, and there’s a slight problem: we don’t have any gloves. A combination of a lack of fuel and a lack of funds has meant that basic supplies can’t be obtained.
I knew I was going to a rural hospital in an impoverished area. I knew I wasn’t going to be surrounded by doctors, RNs, drugs and MRI machines. I understood the hospital would not have a little shop selling balloons with ‘It’s a Boy’ written on them. But I really, really didn’t think I’d be working at a hospital without any gloves.
Most days in the maternity ward began with one of the nurses doing the rounds of all the other wards to beg for a few pairs of gloves. When even that source dried up, women stopped getting vaginal exams and we delivered babies wearing heavy-duty rubber cleaning gloves. In an effort to protect themselves from HIV, some staff would wear the same pair of gloves when going from patient to patient.
WEEK SIX: WE RUN OUT OF IV FLUIDS, AND THE STAFF DON’T GET PAID.
Week six and I’m still in maternity. We’ve got hold of some gloves (some are those loose gloves you get with packets of hair dye, but some are actual hospital gloves), but we’ve run out of IV fluids and oxytocin. Meanwhile, the staff haven’t been paid for two months. The whole village is suffering as a result of this; in an area with around 95% unemployment, the hospital staff are the only people with any disposable income to spend in the tiny shops that line the main street of the village.
I realise that I’m surrounded by people who haven’t been paid for months, who often have no means of protecting themselves from HIV or other infections, who are dealing with children dying every day, and who are still turning up to work and doing their best.
WEEK SEVEN: WE RUN OUT OF CHLORINE.
I had been wondering why the hospital smelled like Lambton pool, and now I know. The only cleaning supplies are chlorine and Vim. Every morning, the hospital cleaners do the rounds of the stone floors with a mop and some chlorinated water. Except that now we’ve run out of chlorine, so the entire hospital is being cleaned with water alone.
WEEK EIGHT: WE RUN OUT OF SYRINGES.
The entire hospital has now run out of syringes; some wards are re-using syringes on patients who require regular injections.
I think maternity is the hardest place to be– I’m spending part of almost every day desperately trying to resuscitate a neonate whilst his or her agonised mum looks on. I think this is the worst thing. I was with my father when he died, and for months afterwards I would see his face at the moment he died whenever I closed my eyes at night. I can only imagine what the mums of these babies see when they try to sleep – virtually their only memories of their baby will be of frantic resus efforts failing.
I am incredibly lucky that the hospital is currently home to “Dr Ross”, a Scottish obstetrician in his 70s who spends six months of every year in Malawi. There are many, many children alive today solely because he was there when they were born. He is keen to teach me, and tells me it’s OK to be unable to sleep. 50 years into his career, and he still feels the same every time he loses a baby.
WEEK NINE: I RUN HOME.
I come home to a comfortable house, running water (hot water!), three meals a day and a constant supply of electricity. Six weeks later, I’m back in a major trauma centre watching the hospital helicopter landing and practising my resus skills on a dummy neonate. And planning my next trip to Africa.
INTERESTED IN AN ELECTIVE IN RURAL MALAWI?
Information about Embangweni Mission Hospital, including contact details for the hospital director through whom electives can be arranged, is available from http://embangweni.com/hospital.htm. Alternatively you could just do what I did: google “Malawi” and “hospital” and see what you find.
So you know all the manifestations of Marfan syndrome and have your head around Osler nodes and Janeway lesions, but have you ever heard of Tashima syndrome? Self-named in 1965, the condition is one in which a doctor seeks a “new sign, disease, or syndrome to which his name can be attached.”[1]
