Connection.

I felt some true connection today. It was simple and immediate, completely authentic. Jack was a young Indigenous boy living in a remote community. He and his sidekick Max told me of their adventures. They told me of a simple life filled with a little school and a lot of play. They had the ‘jungle’, a herd of beasts to roam with, and one simple rule, ‘be home by dark’.

I have called this connection because in the half hour I spent with these boys I was part of the gang. I got the goss on which building were the ones to climb on, which dogs were the cheeky ones who’ll give you a nip. There was no complication, no fear of strangers, just a drive for a simple relationship built around play and aided by imagination.

I’m not sure what it was about them, or what it was about me, that enabled the connection. Perhaps the location, if not for the health workers visiting once a week few would see this patch of a half dozen houses on the side of the highway. Perhaps it was a loneliness, in their age bracket they seemed to be the bulk of the cohort and so anyone new to play with is good. Perhaps it was me, I’m a sucker for kids and the chance to go roaming around town with a few boys is pretty up there. Whatever it was the effect was stark, they wrapped arms around me like only best mates do.

I don’t wish to complicate this reflection by looking into the why’s and how’s too much, it would be a travesty to piece apart something so organic. I waved goodbye to Jack and Max, Batman and Robin as it were, and was struck by the realisation that I would never see them again. The profound part of this situation was the complete acceptance of this from both sides. As simply and immediately as it began, it was over. While I was there, the gang was three. Without me the adventure would continue, these boys embodied the ‘eyes forward’ approach I try to live by.

I was reminded to live in the moment. Accept those around you into your adventures. Don’t shed a tear at the end, smile at what was. Eyes forward always.

Strong foundations.

The list of forgotten facts often feels longer than those retained. Retention is hard, the curse of the forgetting curve is against us. Undoubtedly the forgetting curve aids our ability to shed unwanted information. Unfortunately there is great difficulty asking your brain to shed the majority in favour of maintaining the minority that are the important things – the needles in the hay stack of everyday working memory.

I won’t write too much more on the forgetting curve or the means of overcoming it’s deleterious effects. For that, try the Learning Solutions magazine article ‘Brain Science Overcoming the Forgetting Curve’ (http://www.learningsolutionsmag.com/articles/1400/brain-science-overcoming-the-forgetting-curve). Also refer back to ‘How to Study.’ (https://wildermedicine.wordpress.com/2015/01/12/how-to-study-effectively/) for study tips.

For today, I write about what retention of knowledge means.

The other morning I got grilled on the mechanism of alteplase as a thrombolytic. The required details had unfortunately fallen victim to the forgetting curve. The conversation slowed, coughed a few times and stalled like a clapped out 2-stroke. The forgetting curve, the failure to retain, meant that the next step forward was halted. I sit now with a to-learn list based around things I’ve already done. Things I now need to re-learn and try to retain.

Don’t get me wrong, as student we are supposed to make use of our forgetting curve. I recognise that this predicament is inevitable and arguably important. What I am asking for is very straight forward and well known. As students, as junior doctors, as future senior in a variety of fields – we need to review and revise in order to retain.

Why retain?

Because our goal is to build knowledge.

Building knowledge, as with building anything, needs a stable foundation. I needn’t explain what happens to a building with poorly built or crumbling foundations. If the foundations of our knowledge aren’t established or are lost to the forgetting curve the height of our knowledge is inherently capped. Without a strong foundation we cannot go up, without a wide base we cannot go out. We need to retain a base of knowledge to elevate ourselves, we need to establish a breadth of knowledge to be able to think broadly. As future doctors we need to be able to do both of these things.

This sequence of thoughts is by no means novel. However, this morning it was indeed relevant. It caught me unaware and I stumbled. I now recall that the need for alteplase within the early stages of clot formation is because it’s mechanism is ineffective after the irreversible action of factor XIII in stabilising fibrin cross-bridging and strengthening clot formation. The foundation bricks of that gem are firmly back in place now and I am grateful.

The unashamed goal of all medical students is to build a tower of knowledge. A tower with a base that is strong enough and a reach that is wide enough that we might perform as competent doctors. What we need to recognise is that the forgetting curve continually erodes our base. It chips away at the hidden corners, the quiet unvisited depths of anatomy and pharmacology. Sure we can let some bricks go without harm or limitation (looking your way kreb’s cycle). But others, the true foundation bricks, the ones with the weight of towers upon them, must be maintained. Until the point where they are firmly locked in our memory we must re-visit them regularly, carefully patching new gaps, to prevent collapse and ensure continued growth.

Re-visit your foundations. Patch them, care for them, build upon them. Good luck.

JFPP 2015 – A South Oz Adventure

In January 2015 I spent two weeks in a little town called Cleve. For many reasons those two weeks felt like two months. Almost all of the reasons were good, one wasn’t. Like the people I met in Cleve, I try to be a ‘glass-half-full’ kind of person so will focus on the good and touch on the bad only briefly. Let me tell you about my South Australian adventure.

When my location assignment email came through from Sean, on behalf of ACRRM, ‘Where?!?’ was my first thought. I had visited South Australia a few times but never made it far from Adelaide and certainly never taken the extra flight over to the Eyre Peninsula (nor the bus that followed the preceding three flights). I met Donna-marie, or Dolce, as I jumped of the bus in the centre of town. I soon learnt that Dolce was all motherly character and warm smiles. She was my ‘Placement Mum’ and I felt at home immediately.

That afternoon Dolce showed me around town (this took about 12 minutes) and said she be back in an hour to take me out to dinner. I checked into the nurses quarter, without the knowledge that they were haunted of course, and unloaded my suitcase. I had the famous chicken schnitzel for dinner, falling a little more in love with Cleve as I took each bite. Day two was filled with paddle-boarding, a walk on the beach and spectacular views. I met my mentor Gail and her family that afternoon. Her husband Hitchy and I got stuck into home made whisky and he taught me to shuck oysters. I was assured that the medical side of the placement would start soon. Yep, falling in love with Cleve.

Now to the medicine, I was spread between three towns with three different doctors on rotating shifts. I was thrown in the deep end but I was handed floaties as I bobbed up gasping. The support and teaching was fantastic, it was the definition of ‘hands-on’. I learnt skills, I practiced examinations, I spoke to patients, I saw the best of some and the worst of others. It was an amazing two weeks and on reflection, it’s clear I hit the jackpot with my allocation to Cleve.

I’ve completed two of my eight weeks and honestly can’t wait to go back. I miss my placement mum and mentor, I miss the teaching and the community. I have no doubt the good is the bulk of the reason my trip felt far longer than the dates on the calendar. To make brief mention of the bad, I had been married for a total of two weeks when I jumped on the plane to head away. The bad was that I missed my new wife.

The John Flynn Placement Program is a truly wonderful thing. I left Cleve all smiles, both because I had a wonderful experience and because I was on the way home.

See one. Do one. Teach one.

The first two years of medical school are all baby steps. There are no leaps, no bounds, no dramatic progressions in clinical acumen. We dream of expertise in the skills we learn but progression is slow. This is partly our fault and partly a structural feature of our medical education. We fail to train to the point that we cannot get it wrong, our study load fails to allow the time for practical task repetition.

I write today about learning on the job. Eyes forward to the clinical years. Although only nine weeks in it is clear that this is a very different set-up. The leaps, the bounds, the elusive progressions in clinical acumen are now available. At last, what we have been yearning for through years one and two. Let us become competent, let us strive for expertise.

Unfortunately, these things are not a given.

Although I confessed to writing about learning on the job, I suppose I am really writing about WANTING to learn on the job. About seeking opportunity, about doing scary things. I’m writing about the need to be willing to see one, then do one, then teach one.

I’m going to highlight the simple steps I think you should take to achieve the seeing and doing components successfully. Yes, I am writing from a medical student perspective but I expect there may be crossover to other realms of learning.

Step 1 – Have a grasp of the theory.

Ideally, you’ll be across the skill or procedure you are about to see. Perhaps you had warning that you would be seeing this and you dug around to find out some basic steps, some indications and contraindications. If this situation comes to be then please, take advantage of it. Learn, simulate, repeat.

Unfortunately, this will not always be the case. In many situations the steps, the indications and contraindications will have to be learnt after ‘seeing one’. That is ok. Not ideal, but ok. If that comes to be then accept and embrace the opportunity. Why? Because the next time you are in a room where this skill or procedure is being performed it will be with your hands.

Step 2 – Have your ears on the ground, then be honest.

If you are blessed with that supervising doctor that doesn’t happen to be busy (blue moon odds here) you will next be asked to perform the skill under supervision. Wonderful! Accept with honesty that you haven’t done it before but that you are enthusiastic and want to try. Perform your tactical breathing, listen to your positive self talk and grasp the opportunity. Easy.

Now for the remaining 98% of opportunities. They will present themselves in a subtle way. Perhaps you’ve seen the patient for a history, perhaps you brush past the conversation between doctors and nurses. Whichever way it happens, when you realise the procedure or skill is imminent, put your hand up and ask – “Can I please do the …” Again focus on honesty. Assure them that you’ve seen one, you’ve read and become theoretically aware, and you are keen to give it your best. The key component for you here is an acceptance that you must put yourself out there.

Step 3 – You must act confident before you will feel confident.

Confidence is key, both to trick yourself and assure the patient. There is no doubt you will have little confidence in the execution of the skill or procedure. So forget about that. Instead gain confidence from what you know; the theory, the patient, the need to learn, the safety nets around you in the form of doctors and nurses. Again, channel the positive self-talk while you breath to slow your racing heart. There is no shame in errors, only in holding yourself back. Stand tall, steady your hand, and smile.

Step 4 – Reflect, revise and remember.

The experience is one thing. Getting something out of it, particularly any form of competence or confidence, is another. You must reflect on what happened to stand a chance of this. Ask yourself three questions; What did you do well? What can you improve on? What did you learn? Aim for three dot points under each question. I say dot points because I do actually want you to write these things down. It aids the reflection and solidifies the learning points.

After your reflection, within 48 hours, revise the skill or procedure. Think again about which bits you did well and what you can do better next time, in addition to the specific components you learnt. I assure you that through this explicit refection and revision you will remember.

The clinical years do indeed offer the chance to accelerate your learning, to gain quick competence and begin the progression to expertise. But not without significant actions on your part. Be prepared, be honest, be confident. Be willing to see only one before putting your hand up to do one. From there complete the cycle through reflection, revision, and the ultimate assessment of your understanding, teaching those around you.

Good luck.