Introduction

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 5^th 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 4^th 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.

The local hospital

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.

RRP: AU$119.95

Snell, RS. Clinical Neuroanatomy, Seventh Edition. Baltimore: Lippincott Williams & Wilkins; 2009.

RRP: AU$107.80

As stated by Sparks and colleagues [1] in their comparison of Clinically Oriented Anatomy and Gray’s Anatomy for Students, studying anatomy can be a challenging endeavour. This is true even more so for the study of neuroanatomy, which many students find particularly overwhelming. In the neuroanatomy textbook arena stand two ‘gold standard’ textbooks: Neuroanatomy through Clinical Cases, by Hal Blumenfeld, and Clinical Neuroanatomy, by Richard Snell. Inspired by the aforementioned comparative anatomy textbook review in the previous issue of the journal, I ponder the question: Which neuroanatomy textbook is superior, the more established Snell or the newer Blumenfeld?

I begin my comparison with a consideration of their similarities…

Figure 1. Baby hospitalised for suspected bacterial pneumonia.

Squeezing into our rusty mutatu (bus), we handed over the fare to the conductor, who returned to us less than expected change. In response to our indignant questioning, he defiantly stated, “You are mzungu (white person) and mzungu is money.” This was lesson one in a crash course we had inadvertently stumbled into: “Life in Kenya for the naïve tourist.” More unsettling than being scammed in day to day life, however, was the rampant corruption in the hospital and university setting.

We completed our placement at Kenyatta National Hospital, the largest referral centre in Kenya, with 1,800 beds, 50 wards and 24 operating theatres. I was based within the paediatric ward and paediatric emergency department…

Empathy and the medical student – Practice makes perfect?

The observation of another person in a particular emotional state has been shown to activate a similar autonomic and somatic response in the observer without the activation of the entire pain matrix, not requiring conscious processing, but able to be controlled or inhibited nonetheless. [2] This effectively means that when we see someone in physical or emotional distress, we too experience at least some aspect of that suffering without it even needing to be in the forefront of our consciousness. As medical students we are constantly told to “practice” being empathetic to patients and family members. What we are really practicing is consciously processing this suffering we unknowingly share with these people in order to develop rapport with them (if not just to impress medical school examiners).

We are taught an almost automated response to this distress, including a myriad of body language and particular phrases, such as “I imagine this must be very difficult for you,” to indicate to a patient that we are aware of the pain they are in. Surveys amongst critical care nurses have shown that gender, position, level of education and years of nursing experience have no significant relationship with the ability of a person to show empathy. [1] Thus it could be said that empathy is less of a skill which can be practiced until perfect, and more of a mindset that makes us as human as the people we treat…

During my elective term in early 2010 at the Royal Free Hospital, London, I was presented with a fantastic opportunity: to learn how to perform a laparoscopic gastric bypass procedure. The challenge was for myself, a medical student and complete novice in laparoscopic surgery, to use the hospital’s state-of-the-art screen-based simulation technology to become proficient in a specific operation within six weeks in this rapidly advancing area of surgery.

My training was to be undertaken using the Simbionix LAP Mentor (Simbionix, Cleveland, Ohio, USA): an advanced piece of technology made up of a computer with simulation software and accompanying hardware, consisting of ports and instruments. The difference between this and a video game is the presence of haptic feedback; when you hit something or pull it, you feel the corresponding tension, making it a highly realistic representation of surgery…

Prof. Alden H. Harken

As students of medicine, you will soon be educationally unique – with a body of knowledge that no one can ever take away from you.

When you receive your MBBS, the society and community in which you live is making a statement of trust in your abilities. With that trust you will be afforded extraordinary privileges and esteem. However, with the esteem and privilege comes the heavy responsibility of your patients’ well-being. You are all remarkably capable – and, remarkably fortunate to be so capable…

Figure 1. Population pyramid demonstrating the relative youth of Australia’s Indigenous population, 2009.

Surely we don’t need any more research? Surely we know what to do to improve Aboriginal health? Surely we know the best environments for healthy child development? In this article I provide a rationale for Aboriginal child health research, give a history of my own personal journey in Aboriginal child health from the 1970s to 2011, give examples of our research and its application to improve outcomes and how we have provided the environment to build the careers of Aboriginal researchers; and finally, end with several recommendations.

The aims of the Telethon Institute for Child Health Research (TICHR) are fourfold:

1. To conduct high quality research;
2. To apply research findings (not only our own) to improve the health and well being of children, adolescents and families;
3. To teach the next generation of health researchers; and
4. To be an advocate for children, for research and for social justice.

We do all this by…