Career Pondering

• Community Medicine: 2 years of Family Medicine training, 1 year of academic training (get MPH at London School of Hygiene and Tropical Medicine, Harvard, or Johns Hopkins), and 2 years of rotations - gives you flexibility to be clinician, researcher, Medical Officer of Health, health policy consultant, etc.
  
• Family Medicine + Emergency
• Emergency
• Internal Medicine
• Neurology
• Pediatrics
• Psychiatry
  

Graduation Goal

Before 2013: Princess Margaret Hospital's Ride to Conquer Cancer!

PTSD

Took a well-deserved break from studying by watching a movie with some old friends. I don't want to spoil the plot of the movie, but essentially a soldier (who was thought to be dead) unexpectedly returns from his service in Afghanistan suffering from post-traumatic stress disorder (PTSD). While a captive in Afghanistan, he was forced to kill his comrade or risk being killed himself.

When the solider returned to his family, he had difficulty trusting his loved ones. He presented with unusual behaviours, such as compulsively organizing dishes in the kitchen according to shape, size, and height. His affect changed from before - it became incongruent. Finally, he lost his ability to show emotion.

It's hard to say whether the movie made me more or less interested in psychiatry. I've always found psychiatry fascinating for the reason that patients often present with complex and multi-layered problems. Piecing together a patient's situation is no easy task, but the exercise itself allows room for interpretation and analysis. Psychiatry may not be one of the more evidence-based branches of medicine, but it does finely capture the art of it. However, treatment is usually long and arduous (even if you suggest pill-popping), some patients may deny having any mental health disorders, and improvements are hard to measure. With limited techniques and strategies, how do you know you are helping your patients?

WC

Reflections on My 22nd Birthday

Loosing energy and easily fatigued from 9-5 classes. Falling behind in my lectures even though I'm studious. Not leaving enough time for my friends and family. Getting moody, doubting my abilities, and questioning career choices. Unhappy with my learning progress and intimidated by my peers. Cannot express my thoughts clearly to others. Finding emptiness in other people's advice and suggestions. Looking for a confidence boost.

Dx: burnout?

Rx:

Long-term care: re-sparking the debate

Staff at Joseph Brant Hospital in Burlington are asking their elderly patients to go home in order to free up hospital beds for those needing acute/emergency care. Critics of this action suggest that the hospital is really removing, rather than freeing up, these beds in order to reduce their $5.5-million deficit. What strikes me as surprising is that staff are wearing "Home First" buttons to promote this initiative. What impression does this give to patients who absolutely need hospital care? Unfortunately, in order to balance the reality of taking on more patients, especially those with acute care needs, others are left to draw the short end of the stick. This time its seniors, re-sparking debate about the need for extended home care coverage and investment in long-term care facilities. 

A few issues are at play.

There are both advantages and disadvantages to receiving care at home. At home, patients are most comfortable in a familiar setting, can move around more to improve rehabilitation, and are away from any threat posed by superbugs at hospitals. However, the sicker the patient, the more supervision they need. Supervision by health care professionals costs money and currently the province only covers 1-hour worth of services - the rest of the costs have to be shouldered by the patient and their family. Admittedly, the hospital is trying to get churches and community organizations to help out, but the absence of any suitable long-term care facilities makes alternatives difficult to consider. 

One hopes that the hospital is only releasing elderly patients when they are deemed fit to leave. This cannot be guaranteed in constrained circumstances where new patient arrivals dictate the frequency of freeing up hospital beds. Acute care needs trump chronic care needs, but a chronic care patient left unsupervised in their home can easily wind up with an acute care problem. Are they ways in which adequate home care services can prevent this from happening?

My housemate Gabe believes that technology offers a solution. Specialized monitoring systems could be set up at home to provide 24/7 visual access on the patient's whereabouts. In addition, gadgets could be attached to their bodies to provide feedback on vitals and any unusual physical movements. All this information could then be fed into a data processor where people would work around the clock to monitor the health and safety conditions of hundreds, if not thousands, of patients living at home. Could this work as a short-term solution? 

WC 

Teaching Evaluation

Period 1 Ratings   4 3 2 1 Total  Overall Evaluation of Orgo Instructor?  2  8  2  0  3.00   Was the instructor prepared for class?  3  7  2  0  3.08   Did the instructor make the class interesting?  3  7  2  0  3.08   Was the instructor on time?  11  1  0  0  3.92   Did the instructor move the class at the right pace?  5  6  1  0  3.33   Student 28, Evaluators: 13 Average 3.28   4 = Excellent; 3 = Good; 2 = Satisfactory; 1 = Poor; 0 = Unacceptable

Not bad. Wish there was qualitative feedback. 

WC

Crying Babies

Imagine this. You've been asked to supervise a male infant in one of the pediatric wards. Upon entering his room, you are relieved by the fact that he is sleeping peacefully. It's almost the end of your shift and you welcome some tranquility at last. 

As you take a seat at a nearby chair, you can't help but notice the rhythmic rising and falling of the infant's chest. You remind yourself to look out for any abnormal patterns of breathing. The boy is resting on his stomach and you wonder why he hasn't fallen asleep on his back. You remember from your developmental psychology class that it is generally safer for infants to sleep on their backs with their face to the ceiling. He seems comfortable in his resting position so you don't bother to move him. At least his head is tilted sideways so that you can watch his face while he sleeps. 

After the fascination of scrutinizing the baby subsides, your mind starts to wander. You start to think about your plans for the afternoon, for the rest of the week, and ultimately for the rest of the summer. A TV is right beside you, but you know better than to turn it on. If a parent walked in, you wouldn't want to be caught doing anything other than supervising their precious child.   

Suddenly, the infant blinks. Is he waking up or just teasing you in his sleep? He blinks again and his eyes widen. He's awake! You haven't played with an infant in a while, but you are ready to at a moment's notice. 

He starts crying. Not surprising. He probably misses his mom or dad and feels threatened by this random stranger in the room. Predictable attachment response for an infant at this age. You try to use soothing words to calm the baby, but to no avail. 

Next, you try rolling him over on his back to facilitate more open communication. Your maneuvers are clumsy and sloppy. His crying gets worse. 

You try to give him a soother. It works temporarily, but he wants none of it after a few seconds. He redoubles his crying efforts.

Out of desperation, you try to distract him with some toys. He hardly pays attention to them. By now, his wailing hurts your ears and you are emotionally crushed by the tears rolling down his cheeks. Must be a pain response to something medical in nature. 

You attempt the last trick in your books - a cuddle. You haven't done one of these in a while so you're naturally hesitant to take him out of his bed. You note several cords and lines attached to his body, which complicates getting a firm hold on his limbs and torso. Forgetting to swathe him in blankets, lowering the guard on the bed, and giving him enough neck support are only a few mistakes you make while performing this intricate move. He cries more intensely to signify your failure to attend to his needs. Frustrated, you put him back down on the bed. 

Despite years working with children and being a regular volunteer on the pediatric ward, you feel a strong uneasiness about what to do next. Besides being unable to calm the baby, you are not even certain about why he is crying. 

Feeling helpless, you're about to give up when a nurse suddenly arrives. Remarkably calm, she provides words of encouragement, explains why the baby is crying, and thanks you for supervising the child. It's her turn to take over now. You feel undeserving of her appreciation. 

As you exit the room with a hanging sense of defeat, you wonder what you would do if the nurse didn't show up.

Am I ready to respond to an emergency?

Last weekend, I did a course on Standard First Aid and CPR. If there is one thing I took away from the experience, it would be the following: saving a person's life in any emergency situation is of utmost importance. Those with adequate training have a responsibility to intervene in dire situations that call for their expertise. 

All of this seems noble and Good-Samaritan like, but I'm still left with an unsettling feeling. After a weekend of training, I hardly consider myself qualified to handle an emergency situation on my own. If I make a mistake in any step of the life-saving protocol, am I not guilty of doing more harm than good on the patient even though I act out of good faith? Despite sufficient training, making a mistake is a real possibility in the heat of the moment as you race against time to save a life. 

For example, using an automated external defibrillator (AED) can help bring a patient back to life from cardiac arrest by delivering an electrical shock. Although the AED is a reliable, user-friendly, and generally worry-free device, things can still go wrong if metallic objects are not removed from the patient's body before administering the shock. These details are all too easy to miss in the spur of the moment. If death results from this negligence, you may not be held liable due to Good Samaritan laws, but can you truly escape the blame put on yourself? Can you erase the thought that, had you not intervened, the patient would probably still be alive? In this case, fear of adverse consequences and doubt about one's competency are legitimate excuses for inaction. Wouldn't it be better if someone else assumed responsibility? 

I'm at the cusp of understanding not when and how, but if, I can provide care. 

Methadone not good enough?

One of two Calgary methadone treatment centres that services about 500 patients is scheduled to close at the end of this month. The reasons include not meeting city standards for zoning and not adequately consulting with community associations before it opened in late 2008. 

How it managed to open despite these claims is anyone's guess, but is it justifiable that the community associations are legitimately worried? On one hand, they can be blamed for adopting a "not in my backyard" policy and fueling the stigma of those living with substance addictions. But if you put yourself in the shoes of a community resident, having addicts freely and frequently roam your streets may be a good enough reason to complain. 

Let's take a step back and look at the big picture for a second. Closing the treatment centre will leave a few hundred of people without the appropriate care and support needed to wean off their drug addictions. This will be particularly devastating to those who are already committed to their regimens, but that need convenience and habituation to carry themselves through. The risk of relapse will be high, potentially undoing years of hard work on the part of both patients and health care workers. 

Although immediate closure seems like a worst-case scenario, relocation is not that much better. As mentioned, treatment for substance abuse can be long and arduous. If people with addictions rely on routines to maintain compliance, any disruption in this pattern can be detrimental. How big of an impact will moving a clinic cause? I guess it depends on how far away it will be from the greatest locus of clients, how many health care personnel will continue to work in it, and if the services will be delivered at the same level of efficiency. It doesn't help that a 3-month wait time exists at the other methadone clinic, which cannot realistically take on more patients. 

What bothers me is this. Even though science (and perhaps some heart-warming testimonies) can show compelling evidence of the effectiveness of methadone treatment, the needs of substance abusers often come second to none. Are they less deserving of treatment because of who they are or what they do? You would be surprised if I told you that those with drug addictions come from all walks of life. 

Even then, a doctor would say no to this question because dealing with health and health care issues is what unifies all human beings. As Perri Klass puts it nicely, "doctors are engaged with individual humans at the level that makes everyone human." 

On the other hand, a policy-maker (as this is a career path I'm still considering) has to weigh several other opinions, ranging from those of city counsellors to community members to anyone else with a public interest on this matter. Policy-makers sorting through this dilemma would be hard-pressed to take sides between those that are healthy versus those that are unhealthy. Doctors, as advocates for their patients, have a clear position. 

How can someone reconcile being both a doctor and a policy-maker?

WC

Big'ups

Big'ups to the movie Up!

I finally had the chance to see it, and after much anticipation, it still managed to exceed my expectations. Just based on the preview alone, one would think that the lead character, Carl, is just a grumpy old man with nothing better to do than concoct wild ideas of flying a house. Who would have thought that he lived a life that many people only wish they had, of growing old with the person you love the most?

There was an obvious climax to the movie. This was when Carl finally reached Paradise Falls and looked over his sentimental "Adventure Book" for the last time. Up until then, Carl had been living on a unfulfilled promise to his late wife, Ellie. When he flipped through the book, little did he realize that Ellie's adventure began when they got married. It was a heartfelt reminder of cherishing the past and moving on. 

Sometimes we need a wake-up call to remind us of appreciating, rather than, regretting life's journey. Sometimes it takes the most unlikely of characters, such as a chubby Wilderness Explorer, a talking dog, and even an overgrown pelican, to change our frame of mind. Sometimes, embarking on a new adventure happens when we least expect it.

WC