Medical Admission Note: January 2015

Dear patient,

I hope this letter finds you well.

It seems foolish to ask if you remember me. I'm sure you couldn't forget me if you tried. I'm the centrepiece of the worst memory of your life. I was the doctor who broke the news you were dreading, that you had cancer. Stage 4 cancer, incurable cancer.

I'm sure you'd recognise me if you saw me in a crowded room. My face was the last thing you saw before you lost hope. My face destroyed your world.

When you're a doctor, telling a patient they are dying gets easier. It does. In fact, with time some doctors seem to forget that even though this is the hundredth or the thousandth cancer for them, it's their patients first cancer. You didn't know this then, but your cancer was my first cancer as well. Since that conversation I've diagnosed many more cancers, and I've told many more patients they are dying, but your story has stayed with me. Your story, I'm sure, will stay with me for the rest of my life.

I first met you in a busy emergency department. You'd come in with a cough. (Just a cough!) But something wasn't quite right. I had an uncomfortable feeling from the moment I met you. Two years later I've learnt that that feeling- that sinking, nauseating feeling in the pit of my stomach that a patient is much sicker than they look- rarely lets me down. You taught me that.

Your X-ray showed pneumonia and I admitted you, but after two days of antibiotics you weren't getting better. Then the lab called and said your pneumonia was caused by a odd bug. A bug sick people get. But you weren't a sick person. You were 37 and fit. Why did you have this bug? I came back and asked you the same questions I'd asked you in the ED again, but this time you told me different answers. You told me about the weight loss, the sweating at night, the blood when you coughed.

The next day we scanned your whole body, but really we already knew what the answer was. There was cancer everywhere. We think it started in your lung but it was now in your liver, your bones and your brain. Inoperable. Incurable. You probably only had weeks left.

I remember breaking the news to you like it was yesterday. We were both terrified but I was pretending I wasn't. I told you that I was sorry, and I truly was. I hope my voice didn't shake. I hope my face was kind. You cried and my heart broke for you. I wanted to hug you and tell you things would be alright. But I couldn't, and they weren't going to be. I hope you didn't realise that when I left your room an hour later I was crying too.

I took your cancer so personally. I felt that I had failed you by not being able to offer a cure. I cried myself to sleep for many, many nights and tormented myself that if I'd seen the signs the second I met you, or that if I'd taken a better history you could have been saved. I know now there is nothing anyone could have done.

You accepted you were dying long before I did. In fact, I didn't accept your death until long after you'd gone. You weren't the first patient of mine to die, but your death left me broken. I felt like I wasn't worthy to be a doctor. That I should have been able to save you.

You were only with me for 4 short weeks, but in that time you taught me more than many of the professors and teachers I've known have taught me in years. You taught me to be empathetic but wise, compassionate but brave and that being vulnerable and emotional were both my best and worst qualities as a doctor and a human. You taught me that I couldn't save everyone, but that saving people wasn't always what mattered. There were more important things in life - dignity, kindness, being at peace with yourself...

I knew back then that my face was the one that changed your world forever, of what a huge role my character played in the story of your life. You didn't know then, what a huge role you played in mine.

I hope this letter finds you well.

I hope you found the peace I couldn't give you.

Yours most sincerely,

Your doctor.

Here's a little list for the panic attack you'll have the night (or the week) before starting internship. Things you need to do to prepare for your first day as a real doctor:

1. Find your 'system'

Remember when you used to imagine that after graduation it would be all life saving & meaningful doctoring? I hope this isn’t the first time you’ve been told that’s not the case. The best quote I can use to summarise internship is this:

‘I’m okay at treating heart failure, but I’m excellent at sending faxes’

The best interns aren’t the most brilliant clinically, they are the most organised. Hopefully you spent a bit of time in final year med school observing junior doctors systems and have seen what works and what doesn’t. The same system doesn’t work for everyone, but these are the basics:

A paper-storing mechanism

Option 1: Lots of people use 'nerd boxes' like this which have a handy clip to attach your patient list at the front, and can store various papers inside. The flat surface means you always have something to write on. You can prevent your papers inside getting mixed up by using paperclips to group like papers.

Option 2: I used a ring binder like this which I attached a bulldog clip to the front of to hold my patient list. I then had my various forms/papers in their own plastic sleeve which meant they never got mixed up and I could find them very easily. A bit bulkier than option 1, but more organised.

Option 3: Haphazardly collect various bit of paper you will need and clip them together using a bulldog clip. This system is the least bulky and you can easily access things, but if you require more than 3 different types of paper/forms, its probably not the best. It also has the advantage of being replaceable if you lose things easily.

Option 4: No system. This is not an option, unless you want your co-intern to hate you (I'm looking at you, surg co-intern)

Blank supplies for your paper-storing mechanism

Basic: Progress notes, medication charts, iv fluid charts, pathology/radiology forms, blood product forms

Med: echo/cardiac procedure forms, any special condition forms (my hospital has a flow chart for pneumonia, CCF, cellulitis), special ward round forms if they exist, consult sheets

Surg: consent forms (x a million), elective admission forms, patient information sheets on common procedures (taken from outpatient clinic)

A way to write down jobs

This seems obvious, but some people don't do this!! You WILL NOT remember things unless you write them down. Every little annoying job you get given you should write down. This job list can either be on your patient list or on a blank piece of paper.
Draw a little square next to each job so you can tick it off once you're finished.

Results (unless the iPads at your hospital work a lot faster than the ones at mine)

Our patient list printing system handily prints off blood results, however its almost never adequate for what your consultant will ask you.
If blood results are available before ward rounds, you should get to work early to write them down.
If not, do a 'blood result' paper ward round after the actual ward round. Don't not check results, not acceptable.
Depending on the rotation/consultant there are different specific results you will be expected to know (HbA1c, CMP, Vit D, serum rhubarb), you'll know after the first ward round.

For radiology results, if the patient has had a CT/MRI/fancy scan I found the best way was to print the report & have it in my paper storing mechanism to hand to the consultant.

Lots and lots of pens

2.     Have a cheat sheet

You can borrow mine here, but I really recommend making your own.
I was really nervous about arriving at ward calls and not remembering what I needed to do for chest pain so mine has a lot of managing ward calls. At the very least write down doses for common drugs.
Even if you remember them all now, there's nothing worse than having to google 'dose of paracetamol' while your consultant breathes down your neck.

3.     Invest in comfortable, professional shoes

Girls, I can't recommend these shoes enough. Expensive but I wore them every single day of internship and residency. Thanks to my wonderful friend Nicola for introducing me.

4. Invest in a satchel/place to put your doctoring things

My doctor bag looks like this and contains: wallet, phone, USB phone charger, so many pens, penlight, lip balm, muesli bar. It should contain a tendon hammer, but it doesn't (Sorry Prof Storey)
You could also use your pockets for this.

5.     Get a GP

I know you think you are so healthy that you don't need one but if you want to stay that healthy, get a GP. One you like. Go and see them early this year and get your OCP/ventolin script, that pap smear/STD check you've been putting off, and let them be proud of you for being a doctor. If you're super lucky you'll only need to see them once a year for this visit. If you're like most of us type A anxious types, you'll see them more often.
If you email the Victorian Doctors Health Program they will give you the names of GPs willing to treat doctors in your area.

6. Accept you will feel very stupid, very often

Oh how I wish someone had told me this before internship started! I was a good med student and I thought that meant I would be a good intern. I don't think anyone actually feels like they are a good intern. You will feel like you know absolutely nothing most days, and the only reassurance I can give you is that everyone else feels the same way, they're just hiding it very well.

Internship is super overwhelming! It's totally normal to cry on the drive home (but not every night).
Make sure you have a good group of medical friends to debrief with & some non-medical ones to remember how to have real life conversations with.
Take up those hobbies you have neglected for all of medschool. Go for a run. Don't drink too much wine. Call your mum.

It will be okay. You'll survive. :)

Medical Admission Note

Saturday, 24 January 2015

A letter to my patient with cancer

Sunday, 4 January 2015

About to become a real doctor?