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.

Living and Learning.

It happened, I missed a blog. I actually missed two. In the name of confession I also haven’t run for 14 days days and I missed 13 days of studying any medicine. Not ideal but fair given the circumstances I’ll recount below. Important to know at the outset is that this is indeed a long blog, apologies.

I write today about living and learning. Irrespective of circumstance.

I learnt a lot in the past fortnight. I learnt to listen to my body. To trust my intuition, even my inexperienced medical intuition. I learnt about the joys of a caring nurse, and the potential discomfort at the other end of the spectrum. I learnt a little about pain, a bit about dignity. I learnt that ‘eyes forward’ isn’t just about work or sport. I learnt that having family around at tough times makes them far more manageable. I learnt that the predictable ups and downs I’ve come to love when running an ultra is mirrored in illness. I re-learnt about smiling and accepting because at times there may be little else worthwhile.

A great photo on Twitter yesterday showed the normal squiggle of an ECG with a caption along the lines of ‘without ups and downs in life you’d be dead’. I had a down last week. I’m on the up again now. By definition, I am alive. As I write about these ups and downs I will maintain that this is not a whinge. I realise that the absolute level of ‘hardship’ here is low. I am incredibly fortunate and am very aware of this. I write simply and honestly about the things I have learnt. The little things. Read on and you might learn something too.

It started with a tummy ache. Boring I know. ‘I don’t have time for this’ was about the extent of the thought I gave it for the first two days. The ache persisted, it was now accompanied by tenderness. The medical brain kicked in to gear as I took my history. Bowel habits? Fine. Fever or any other signs of illness? Nope. Change in appetite? No. Localised or diffuse tenderness? Diffuse. Or is it….? I’m sure I’ll be fine.

That night I half-jokingly said to my wife Carly:

‘I think I have appendicitis, if I wake you up in the middle of the night with severe pain just chuck me in the car and drive me to ED.’

The basis for learning point number one – listen to your body and trust your intuition.

I carried on with life, wondered about a musculoskeletal cause for the pain. I was still running everyday, I stretched the crap out of my hip flexors, it was still a boring story. At most the pain was a 2-3/10, maybe a little worse with some poking and prodding. Starting to localise….? ‘No I’m being paranoid!’ Or maybe… ‘No don’t be stupid.’ I chastised myself.

Placement was going well, I was ticking off experiences, getting along well with my supervising doctors and seeing lots of patients. It got to Friday and a little relax time allowed me to slow down, perhaps to tune in with myself a little more. ‘Hmmmm… Is the pain getting worse?’ No it’s fine. What happens if I poke my appendix? ‘Ouch.’ Hindsight is beautiful but at the time I was in the denial stage. 26 years old with some lame abdominal pain. Must be a viral cause, a bit extra sleep for a few days and I’ll be fine.

I studied most of Saturday then hit the bush and knocked out three repeats up the nastiest black mountain trails. Hard hiking on the way up, bombing the downs – prep for that 100km ultra in May was going well I thought as I drove home exhausted. Arrive home and hold on a minute…. Pain started to climb. 4/10… Maybe 5/10. It was a little more local, a little more tender.

‘Could still be my hip flexors, hey babe where is the foam roller?’

Ah hindsight.

Sunday morning I was sore. ‘Ok fine, I’m going to the doctor.’ I was heading into the acceptance phase now. I tried to elicit rebound tenderness (turns out very hard to achieve on yourself), continued to poke and prod my right iliac fossa out of curiosity. I was headed to the hospital to study so I booked a 10:40am spot at the after hours GP. Sitting in the library trying to study, pain 6/10, sore to move, slow to walk. It was 10am on the 5th day of some boring abdominal pain and I brushed passed full acceptance. I called Carly, told her I felt like company at the doctors and went to pick her up. I love her and I love her company but this was about forward thinking, not loneliness – if I had appendicitis I would be bounced to ED and admitted for surgery whenever they could fit me it. What good was it if Carly was stuck at home without the car, I had better go pick her up. Carly later recounted her disbelief at how calm and collected I was that morning given I knew I was likely headed for admission and surgery.

The GP I saw just about giggled when I told my story and she examined me. Her smirk was so evident, ‘this is classic appendicitis, are you sure you’re a medical student?’ was the sum of the sentiment. I strolled down the corridor to ED, handed over the hastily typed referral and grabbed my spot in the cue.

‘So did you just ask me to come down because you thought you would be admitted?’ Carly quizzed with a cheeky grin.

Busted.

If I’m honest, the whole thing was a little underwhelming. For perspective, in an ultra last year my right knee hurt easily two times as bad as this for the final 60km of the race. ‘Surely appendicitis should hurt more than this?’ was the thought circling my head. This was quickly put to rest by the ED doctor, every nurse that heard the story, the surgical registrar who came down to consult with me, and the two interns in ED who had been my senior classmates last year.

In the hope you might read this full post I had better speed this saga up. Although it is far from the climax.

Admitted on Sunday, fasting fasting fasting for surgery tonight right? Guys… Hello? I was kidding myself, it was a long weekend and I was a boring story that would be easily bypassed by a busy theatre. Fasting fasting fasting for surgery Monday. Ok cool, surgery done. No trepidations around this aspect. Past broken bones mean this was nothing new so bring it on, ‘fix me!’. All seemed to go well. ‘Crunch down endone for a day or two after discharge and I’ll be away again’ was the idea in mind as Carly drove me home.

Tuesday night and Wednesday weren’t fun. The endone (3 every fours hours in addition to the panadol and nurofen) wasn’t cutting the mustard. Mild concern. It felt so lame to be so incapacitated, Carly had to help me get up from a chair, get down to a chair, get into the shower, sit up in bed. I had to close my eyes and block my ears when we were watching a comedy show on TV, laughing was unbearable. If I coughed I winced and broke out in a dramatic sympathetic sweat. It appeared that abdo surgery was a different recovery process to shoulders and wrists…

I woke in a daze about 9:30pm on Wednesday night. A new symptom had arrived, overwhelming nausea… I did the complicated manoeuvre to get myself from lying to sitting and lurched to the bathroom. The vomiting started. Coughing had been bad, deep retching and vomiting was far worse. I sat on the floor and filled the base of the bath with what looked like everything I had eaten since the surgery. Semi digested food, bile. Lovely. I didn’t want to wake Carly so I went to the dining room table and tried to sleep sitting upright with my head on a pillow on the table top. I woke an hour later in a puddle of drool and lurched my way to the bathroom again. I filled and re-filled the sink with more internal contents. Again, lovely.

My medical brain started churning about the new predicament, attempting to put the pieces together. Abdo pain worsening steadily (now worse than that blasted knee pain in the ultra), recent surgery, profuse vomiting, no bowel motions since before the surgery, now unable to urinate either. Hmmm SBO? SMI? I wonder if I have any bowel sounds? A quick listen with my stethoscope said no to this question. I gave in.

‘Hey Carly, I think I need you to take me back to hospital.’

Basis for another learning point number two – having family around at times of hardship makes them far more manageable.

She was great. ‘Ok no problem, give me 5 minutes to get dressed.’ We got to ED about midnight, every bump on the way there gave a corresponding cringe and more vomiting soon followed. I filled a plastic back with what was surely the last of whatever I had within me. Unfortunately we arrived to a busy ED, about 15 people sitting around displaying the full spectrum of discomfort. The triage nurse listended to my story, gave me some ondansetron to settle the nausea and asked me to take a seat.

For fear of a rant breaking out I won’t go into my thoughts around this part of the story.

I alternated between a hunched ball on a chair and an absent figure perched over the sink in the bathroom continuing to empty my guts. My mate Aidan once drove me 2.5 hours from a remote farm to the hospital with a suspected dislocated shoulder. Upon arrival the ED doctor tried for 10 minutes to ‘re-locate’ my shoulder. The subsequent x-ray showed I had a broken humerus rather than a dislocation. The pain during the ‘relocation’ was indescribable. This ED abdo pain was climbing to those kind of levels. At 3:40am we were asked to come through…. Under the four hour mark. Again, I won’t go into my thoughts on the triage system in practice there – eyes forward.

By 4:30 I got to see a doctor and was administered some IV morphine. Pain below 10/10 again, winning. Examination showed guarding, diffuse tenderness again localising to the RIF, afebrile, few bowel sounds, peripherally pretty shut down. Thankfully an X-ray showed no big dilated bowel or signs of obstruction, winning again. ‘Surely I’m too young for SMI’ I remember thinking. ED doc heard the story, intern heard the story, surg reg brushed past for an opinion, I even got to see the consultant surgeon. A catheter went in and a litre of urine poured out, ‘Well there goes part of the problem’ I remember thinking. I was a bit more comfortable now so it was off to CT to figure this thing out.

Result – first surgery left a ‘normal’ stump of appendix. This stump was now misbehaving. It appeared to have an appendicolith within and was surrounded by heck knows what. There was fluid all over the place. The surgical report would later talk about an abscess, omental adhesions, pus and fluid through the paracolic gutters. All the fun stuff.

Thursday morning in a busy ED had me out and into a ward by 10am. I went back to my brief home from earlier in the week, I was kindly welcomed back by the nursing staff, consistently facing the light-hearted question, ‘did you miss us?’ The CT results meant another surgery, a second appendicectomy (or appendectomy for any American readers). Moreover, it meant a slow recovery, an extended stay with more fasting fasting fasting both pre- and post-surgically.

Gosh they were quick this time. I was in the OR by early afternoon. I was in a recovery daze with two lovely nurses not long after (the joys of general anaesthetic). Back in the ward I was sore. Carly was there by my side but I was hopeless. Consistently and completely reliant on her to do everything. My dad had come to town when I first headed into the hospital. He would later come down again when I was going through the joys of this recovery. Dad oozed kind eyes and practical help while he was there. He brought down a motorbike mag for me to read, sat with me in the hospital as we watched the F1 beaming to us from Melbourne. Yep, family is a necessary component. When neither Carly or Dad were around I prayed for nurse Kim to be on duty.

The basis for learning point number three – a caring nurse is a true angel, their value cannot be underestimated.

I want to detour here momentarily to explore this. I’m a people watcher by nature, always trying to be attentive to that and those around me, to ‘Be here. Now.’ as it were. Anyone who has been in hospital will likely speak of a spectrum of nursing care, or all medical care for that matter. There are outwardly and obviously caring nurses, and at the other end of the spectrum there are those that are unintentionally less caring, less compassionate. I bring this up not to whinge but instead to plea that you, in your role as a health professional or a family member of someone unwell one day, try to aim for the rosy end of the spectrum.

I reflected a lot during my hospital stay about what things defined good care. I went round in circles as I thought about this. I dismissed all the frequently quoted ideas about type of training, age, ethnicity, or sex. I think these things matter little. Instead, I came to the simple idea that a good nurse (or any health professional, or family member) has one simple empathic desire at the top of their list – to give people comfort.

Let me explain.

My beloved nurse Kim would come to take my middle of the night vitals in a completely different fashion to other nurses in the ward. In a way which left me as comfortable as I had been before she came in the door. This involved no single bit of technical skill, instead it focused on doing the required job and leaving me comfortable again. Kim would knock quietly and spread the curtains. She would gently wake me and ask how I was feeling. Kim would explain what she was doing, help me manoeuvre myself appropriately then do the jobs needed, heart rate, blood pressure, temperature, respiratory rate. Kim would ask if I needed anything else then explain when she would be back next. Lastly, Kim would shuffle out quietly and close the curtains again. I would drift easily back to sleep (well, as easily as was possible), having not been startled or worried for a second. If I’m really honest, the closing of the curtains was the most distinctive action that caring Kim, and other nurses in her realms, did over the other-end-of-the-spectrum nurses. This was the bit that showed she wanted to leave me as comfortable as she had found me. It was empathy in an action, it was compassionate.

Again, I write all of that not to whinge. Instead to express concern for the people stuck in hospital for months on end with truly terrible health conditions. I also hope to educate and in that vain I urge you to be caring and compassionate when dealing with patients. Think about, and even ask them openly, what they need to be comfortable. Close the curtains when you leave. I will be trying to do all of these things when I get see patients from now on.

My stay progressed slowly. If I’m honest, the two days after the surgery were shit. I was exhausted and couldn’t get comfortable. I don’t want to belabour this point though, instead I mention it so I can talk about turning the corner and feeling better.

Basis for learning point number four – ups and downs in physical and psychological state aren’t just a feature of ultra’s.

If you’ve ever run very long distances, or completed any really long distance events for that matter, then you may know what I am talking about. In my first ever 100km race I had a bad patch that literally lasted hours. Everything hurt in this patch. Feet hurt, so did knees, hips, back, shoulders, neck. My running slowed down and even walking became hard. Then the strange thing happened… I  started feeling better. The crap patch lifted. My legs started to loosen and my pace picked up. I was smiling again. I went from thinking there was no way I could make it the full 100km to knowing that I was going to make it.

As you go further into events like this things get more interesting. You won’t keep your high. Instead, you’ll drop low again, even lower than before. Then you swing wildly into the sunshine and rainbows again, higher than you were last time. The further you go the faster than mood swings occur and the more extreme they are. When you go beyond 10 or 12 hours in an event like the mood patches can last only minutes before the next swing. You learn to smile your way through the crap patch, grasping tightly the knowledge that if you just keep putting on foot in front of the other it will pass.

On Saturday morning, two days after the second surgery the pain seemed to drop. My in-dwelling catheter came out. The daily heparin needles seemed to hurt less. I had my first shower in days. My mood shifted upwards and a light flicked on at the end of the tunnel. I got my good patch back. It’s now a few days post discharge and I’m clear of the race it seems. I did manage to come out with 10% less body weight, a few new scars, and horrible attempt at a beard but I’m better, and that’s the main thing I believe. In summary, I learnt four key lessons in my time on the ‘other side’ of health care.

  1. Listen to your body and trust your intuition
  2. Do not be afraid to ask for the support of those close to you
  3. Give the patient what they need to be comfortable, be empathic, kind and compassionate
  4. The bad patches will come, and then they will go, smile to let them pass

I’ll stop here for now. This is by far my longest blog and if you’ve read this far I thank you. To me this period of time assured me that there are things to learn in all circumstances. The tricky part may be to tune in to this.

See you next week.

Back to medicine.

Getting back to medicine is a nice feeling. I say this because when juggling a few others balls study time isn’t at a leisurely pace, nor is it ever as long as I’d like. When I do sit down, with my email switched off and some music going, I feel more at ease. I can focus on the patient’s complaint from earlier today, I can choose the learning objective to focus on. It’s like switching gears, and gosh it feels good.

I’m not one to stop readily. Nor are you I suspect. Modern times appear to demand a high pace, there is the expectation of a state of urgency, of always being available and ready to act. Some people thrive on this (ED doctors??), others prefer meticulous work with all of the same importance but stripped of the urgency (anatomical pathologists??). Within the medical world we see a stark contrast when comparing the demeanour of the pressure seeking retrieval medicine specialist to the anatomical pathologist. There also appears to be this same contrast between different roles held by the same person. Or between different tasks within the same role. Let’s explore.

I recently read a few articles describing tasks on two intersecting spectrums. Heading in one direction we have the urgency of a task. At one end, those that must be done yesterday, at the other end the ‘when I get to it’ jobs. The intersecting spectrum consists of task importance. This is equally diverse, at one end the really important things. And I mean really important, like planning your life goals or marrying your long-term partner (urgency often at play here I suspect…). At the other end is to buy that spare box of paper clips because you’re halfway through the current one.

The above idea then defines four categories for tasks:

  1. Both urgent and important
  2. Important but not urgent
  3. Urgent but not important
  4. Neither urgent nor important

So to today’s reflection. Today I write about changing gears to suits the tasks in different categories. Specifically, how to get into the right gear, the slower and more thoughtful gear, for category two. I find this hard given it is surrounded by urgent tasks.

Take now as an example. I sat down for some category one and three time. These require the same high gear so I figure it’s best to aim to knock some over in the same sitting. The intention was to spend an hour in that gear, in the midst of the urgency, before knocking back a few gears and getting some category two tasks done (yep that’s right, category two is all about learning medicine). How wonderful a plan that was. Oh how my intentions were pure….. Oh how I missed the mark. Three hours have gone by and I am still in urgent territory.

This is what happens when you don’t change gears properly. I got caught up in urgency, forgot all about importance and now it’s after midnight. I’ve got buckleys of getting decent study done now (so I might as well blog?). I’m sure many people experience this, grand plans of knocking over those few urgent jobs before getting down to important things. I’m sure many medical students do this, quick trip to the shops for supplies before swinging by Joe’s to pick up the… and while I’m out I’ll just… and then I swear I’m gonna study this afternoon. Urgent gears are hard to get out of sometimes.

So what do I need to do to prevent this happening again? I plan to use stop signs. I accept that it’s fair to knock over category one first. These are true priorities that do have time pressure so go ahead. But if you plan, like I did, to make use of the high gear by doing some category three jobs you must put a stop sign in place BEFORE you start. This stop sign might be a time limit, “i’ll do 30 minutes of…”, or a specific number of jobs, “ten emails and I’m done”. I didn’t set a stop sign tonight and guess what, I never stopped. Urgency grabbed hold of me, and yes I do love this feeling at times, but tonight I got dragged along for a ride. I missed my chance at getting important work done, I missed my chance to visit category two – getting back to medicine.

Whether you’re the ED doc, the pathologist or the medical student you have tasks that need different gears. Don’t let urgency ruin your chance to have a crack at importance. Spend more time getting back to medicine.

Not compatible with life.

I’ve written about having clear goals and looking to heroes as ways to live life effectively. These things give us the direction to go, they keep us on track. A second part to this is the need to let go of things that aren’t aiding these goals, things that wouldn’t be done by the heroes we look to emulate. In order to live the life we want, we need to let go of the things that aren’t compatible with that life.

I write today to reflect on the need to stop doing the things not compatible with the life we want.

I’ll be honest in saying I have a few bad habits and behave terribly sometimes. I’m sure I’m not alone in this regard but I don’t believe the term ‘safety in numbers’ applies. Reflection has given some clarity and some desire to change. I have big goals and great heroes. If I am to achieve these goals and emulate these heroes my actions should be compatible with them, they should be actions that help rather than hinder.

I won’t go into the details of my bad habits. I don’t think that would help. My hero Kim once said to me, “Chris, don’t you ever, ever, ever look back.”, I’m going to channel that. Eyes forward, embrace change, realign my actions. I’d encourage you to do the same. Pick something that is not compatible with your goals, something like smoking or drinking, too much TV, giving in to stress, and let it go. Be honest with yourself and be brave. If it’s not helping, it’s probably hindering so eyes forward and embrace new things.

I attempted a career racing motorcycles. I never quite got there but it taught me a lot and I still think about the lessons I learnt. I learnt about perseverance, about helping those around you. I also learnt, very practically, that when racing there is no point in coasting. You need to be either accelerating or braking, coasting is not helpful, coasting is a hindrance. Having behaviours that aren’t helpful is like coasting, you know you shouldn’t be doing it but you catch yourself there every time.

Fear often held me back when I was racing. It once caused me to hesitate on the up ramp of a jump, I stood when I should have seat-bounced. I came up short on a twenty something metre double and wound up with a broken humerus. Hindsight is beautiful isn’t it, why oh why did I hesitate? I wish I hadn’t, I wish I’d been braver and fully committed. While I no longer race motorcycles I’m sure the lesson I learnt there can still be of use. Giving in to fear is a hindrance, it’s not compatible.

I have picked a behaviour I don’t like, a behaviour misaligned with my goals and heroes, and I am going to drop it.

Maybe you should too.

Progression, not perfection.

As a medical student, there isn’t time to be perfect.

As I’ve written about before (https://wildermedicine.wordpress.com/2015/01/12/how-to-study-effectively/) I spent the early months of medical school making perfect notes. Hours and hours of work to get the finished product. I watched some of my classmates do the same thing. They went for the details, chasing the perfect summary, the perfect diagram, they constructed beautiful notes with all the colours of the rainbow.

“But the world doesn’t reward perfection….”

In the end, we ran out of time. The first six months of school had accumulated somewhere upwards of 150 lectures. When exam time rolled around, the breadth of material we had to cover was quite staggering. Our rainbow notes and perfect summaries of the first few weeks were pushed aside as exams crept steadily closer. We needed to plough through content, those of us realising this changed our focus. Progression, not perfection, was the name of the game.

“… It rewards productivity.”

Peter Bregman, quoted above, could easily have been writing about medical school. “How to Escape Perfectionism”* was published through the Harvard Business Review** last year. I read the article long after the experiences of first year exams but the sentiment captures the situation perfectly. Passing our exams was about progression, not perfect notes and pretty pictures.

Bregman describes the trap of perfectionism. One where projects are slow to start, take few steps forward and rarely finish. He points to a focus on getting every detail perfect as the cause for this. Again, he could have easily been writing about medical school. The perfectionism trap is rampant in this sphere. Example; you’re crawling through a metabolic biochemistry lecture, the krebs cycle is taunting you, it hides it’s details in dusty textbooks and a maze of wikipedia pages. The perfectionist in us tells us to grab the highlighters and a fresh sheet of paper. We draw picture after picture trying to get it right, to ingrain each step, to memorise every active enzyme. If we can just get the colours to match, the picture will be perfect and surely we’ll remember…. STOP!!

Learning the krebs cycle should be about broad brushstrokes, a few keys steps and the rate-limiting enzyme. Get those things in your head and move on. You don’t have time to get that picture perfect. The next 149 lectures are pleading for you to move on.

“… productivity can only be achieved through imperfection. Make a decision. Follow through. Learn from the outcome. Repeat over and over and over again.”

Bregman discusses this change in perspective on a much larger scale. He applies it to life, to happiness. He points to the people of Iceland as an example. They are the “happiest people on earth” due to their ability to be imperfect. They forgive themselves for imperfection, and the associated progression, and can therefore forgive others. Failure is not stigmatised so they are more likely to try new things. Being good at something is not perceived as important. Instead, they get an idea and go for it because failure does not matter, because they are happy to not get it right the first time. This ability to seek progression rather than perfection grants them unrivalled productivity. As medical students I think we need to channel this.

When studying we need to make progress, not to be perfect.

* Peter Bregman, How to Escape Perfectionism – http://peterbregman.com/articles/how-to-escape-perfectionism/#.VN6Ap8btXjI

** Anyone with an interest in these types of articles, or anything business and leadership related, should sign up to the free version of the Harvard Business Review website. You can set your preferences for the types of things you want to read and the site will make suggestions for you. Signing up to the free version grants you access to 15 articles a month. Go here – https://hbr.org – and click on the register bit down the bottom.

Why I have heroes.

I’ve listened to Cliff Reid’s ‘How to be a hero’ talk about a dozen times now (http://emcrit.org/podcasts/how-to-be-a-hero/). I get choked up every time when he talks about his heroic mate Mick. It’s an inspiring, heart felt, and very brave presentation. I like this talk not because I want to be a hero but because I want to hear about heroes, about heroic acts. I think we need to so that we have the chance to adopt these stories, these people, as our heroes. Today, I write about why I have heroes and what they do for me.

I think we should first differentiate between being a hero and having a hero. In my simple brain, I consider having a hero as having someone you look to, or someone you think about, when you’re faced with a tough situation. Maybe this is someone who displays the traits and behaviours you admire and you therefore look to emulate them. As a simple extension, I consider being a hero as being the person displaying the traits and behaviours that others are looking to emulate. Further, heroic acts are ones that others will look to emulate.

Considering the traits and behaviours that I admire, a hero is a selfless person. A hero acts for good, for others, in the face of adversity, in spite of this adversity, they are relentless. They even seek the challenge, pursue the chance to push themselves. They are curious, constantly smiling, kind, patient. They have empathy and understanding. I have heroes, people who act in these ways, so that I might follow their lead.

I have three main heroes; my Dad, Kim, and my Mum. I have many other people I consider heroes for their actions in different circumstances; Cliff Reid, Cliff’s mate Mick, Travis Pastrana, my wife Carly, the best man at my wedding Aidan, my best mate at med school Blair. Each of these people, each of their stories, inspire me to act in the ways I outlined above.

My Dad is selfless, never making a decision or taking a step without first thinking of his children. There are four of us lucky enough to call him Dad. For much of my childhood he was by himself with all four of us were under the one roof. He continues to work tirelessly so that we each have opportunities. So that the world is our oyster. He has an incredible work ethic and is incredibly generous. That’s heroic to me. I hope to be a dad like him.

Kim was a part of the push that got me to medical school. He is forever curious, forever learning. His knowledge of all things, and I really mean ALL things, is astounding. He taught me about truly setting goals. Big goals. He taught me to pursue them relentlessly. His body continually fails him but he doesn’t “have time for that” so he moves on, his will is strong, at times he is ruthless. Kim taught me about managing people. He offered endless words of wisdom in this sphere (“There are no difficult problems. Only difficult people.”) and was kind and ever smiling. That’s heroic. I hope to be like that.

I can’t remember my Mum ever actually yelling at me or getting cross with me (can’t say the same about my younger brother….). My mum can always, always, always see the positive in a shitty situation. She can sit with you, when the tears are rolling, and be tender and patient. She’ll listen, offer a wise quote from Russ Harris or Stephen Covey, hug you and push you back on the right path. My mum is honest to the end. She worked in Kings Cross as a counsellor for 15 years or so. She’s seen it all (and done most of it I think) so she’ll never judge and can see the ‘why’ in every crap decision you make. She is the definition of empathic. That’s hard, and I think it’s heroic. I hope to be like that.

I could continue on about the other people, the other actions that are heroic to me but I think you get the point. I think I’m a better person for having heroes because they are a guide. They offer a reference point for how to act, why to act, when to act. As a student, as a young man, as a budding doctor, I feel like I need heroes.

I think you probably do too.

Replenish your motivation.

Back to school today. A fresh start, a new beginning, start of a new chapter. Words words words, so what do all these cliche’s actually mean for us students as we kick off a new academic year?

I write today as a means to get motivated for what is to come. A year of learning. Minimal holidays. Long hours. Consecutive weeks where my biggest expense will be coffee.

I’m heading into third year, which at ANU means the start of the Phase Two – the clinical years. It does feel like we’re a few steps closer to real medicine. Like maybe we’ll be part of the team this year? Surely we’ll now be seeing many more patients than books. That said, our previous head of clinical teaching referred to our position as medical students as being the bottom of the bottom. With a wry smile and a giggle, we would be assured that only when lucky enough to make it to an internship could we consider ourselves as having graduated to the bottom step of the ladder. So at two years down and with two to go, our cohort is slightly off the ground. We’re halfway to the bottom step of the ladder. Yep, time to get that motivation happening.

Today’s post is about where to find it.

The early years of a medical education are thick with interrogation – ‘Why do you want to be a doctor?’. If I’m honest, I hate this question. I don’t believe the details of our ‘why’ even matter. Perhaps I am biased. For me, medicine was not a lifelong goal. There are no family photos of me with a teddy bear and a stethoscope. My ‘why’ seeded during time with patients in a clinical setting. My hat was that of an exercise physiologist but I got to love the people side of the health industry. I was lucky to have some influential people in my ears, my desires shifted and I started my GAMSAT study. I haven’t looked back. I won’t follow that tangent anymore for now. I bring it up only to make the assertion that provided you have one, the roots of your ‘why’ are largely inconsequential.

Back to our search for motivation.

I believe that maybe the motivation is in the direction. Perhaps if we have considered the direction we wish to go, and can then see that the steps in front of us are going that way, some level of motivation will push us along. It’s clear that some of us carry higher levels of motivation than others. However, it seems that for the vast majority there is a strong ENOUGH desire to become a doctor that we will do whatever we need to do to get through. I believe that for each of us, the desire (or our ‘why’) gives us the direction, and having the right direction keeps the motivation topped up.

My second assertion for the day: at the outset of a new academic year, whether walking into third year, first year or your final year, you had better replenish your motivation.

For me, replenishing my motivation is about revisiting my ‘why’. It’s about tapping into my desire to be a doctor by reminding myself of the aspects of medicine that excite me. I get excited thinking about the challenge of the career, the people I will meet, the chance to be forever learning. I’ve got no idea where in the medical world this will take me, but I also don’t think that matters (Yet). With two year’s to go, kicking myself into gear is about setting my sights on the bottom step of the ladder. Sure, I know there will be much climbing from that point on but I want to be challenged. I want to see the best and worst of people and to make a difference in peoples lives. This is me recharging my desire.

I’ve been fortunate enough to have just spent two weeks on a John Flynn placement. These were two weeks of confirmation that my desire is in the right place. They were confirmation that this desire has put me on the right direction. Feeling as though I’m on the right direction has given me renewed motivation, it’s given me further confidence in my ‘why’.

So to the advice. As we kick off another year of school revisit your ‘why’. If you are heading into year one, be ready for the interrogation, be assured that the roots of your desire do not matter. Be clear that your ‘why’ is no better or worse than the person sitting beside you. For those further through the program, remember the ‘why’ you came in with. Remind yourself that your current direction, although dull and downright unpleasant at times, is a necessary step. Let this knowledge feed your motivation. Do what you need to get excited again.

Motivation means you will hit the ground running. Coffee will do the rest.

Why you should go to conferences.

Last year I went to around ten conferences, symposiums or special lectures. I left each of them carrying something new, something important (no I don’t mean all the pens…Or a GoPro*). I left each of them feeling inspired in some way, often pushing my post-conference imaginings to be more ambitious and feel more exciting (I should admit they were always quite grandiose). It felt as though I would go home with more understanding of the possibilities, always in awe of the breadth of options for future doctors.

I must admit I often left feeling hungover and a few kilos heavier.

The events ranged from local lectures at ANU through to national conferences in major cities. My favourite speakers for the year were the ABC’s Norman Swan (Future Thinking Symposium in Canberra) and Sydney HEMS doctor Brian Burns (Rural Medicine Australia in Sydney**). Yes I even did the subtle ‘loiter discreetly by the stage’ at the end of their presentations for questioning and pestering. Some conferences were aimed at students but for the most part we would be mixing with a room full of doctors. The general chit chat never left me feeling unwelcome or unimportant, however I would always be very aware that I was lightyears behind in terms of experience.

As a student it’s easy to focus on exams and assignments – I equate this to staring at your feet. Staring at your feet is boring. Your feet are never far away, they’re always looming in your peripheral vision, you have to have them, they even make you feel pretty shitty when you get up close to them. Yep, feet sure are like exams.

Going to conferences gives you the chance to raise your head and look around. To look at something other than your feet. My friends and I fell in love with the clear vision. We enjoyed forgetting about our feet and charged off to go conferences in our holidays, even in the week before our final exams. We would hear amazing medical stories from modest rural GPs at the conference drinks and in the next sentence be offered ‘to come out to my practice over the summer’. For these things I am very grateful as we have since seen that these are people who follow through on their offers.

Unfortunately, I can’t possibly pass on the inspiration in words on a blog page. The inspiration and new found ambition is as much about the setting and the atmosphere in which you sit, as it is about the words you hear. The inspiration is also individual. Not everyone got the same kick that I did as Dr Burns took us through strategic breathing exercises. Not everyone rooted for Dr Swan as he pushed speakers for explicit explanations of the murky messages they were hoping would pass as implicit and therefore go unnoticed.

The point of this post is simply to say that you must go.

Go so that you can experience your own awe and inspiration. So that you can open your eyes to the opportunities out there and meet the people who are able to grant you access to these opportunities. Scour the websites and various social media sources for upcoming conferences. Chase funding from the local and national student societies. Enter competitions with ‘conference entry’ as the prize. Grab your classmates, book bulk accommodation (bulk means cheap), car pool for transport.

There may be other ways to be inspired (podcasts and other blogs perhaps) but I believe there is no better way to package the inspiration, networking and opportunity that conferences enable.

And yes, there will be many pens.

*Perhaps the best material object that I left a conference with was a GoPro. This was courtesy of winning the 5k Fun Run at the Rural Medicine Australia Conference in Sydney. They called out “Woohoo you just won a GoPro!!” as I crossed the finish line…. I what??? Needless to say I was pretty bloody happy my competitive edge got the better of me.

**I just about hit the “red zone” (in joke for those who were there or have heard of the zone concept from the book ‘On Combat’) when Dr Burns starting laying it down on stress inoculation and critical care medicine in the retrieval setting. For those interested in finding out more on this go check out Scott Weingart’s EMCrit podcast (http://emcrit.org/podcasts/motr-mike-lauria/).

Do things that scare you.

A few years back I was in my car driving from Sydney to Canberra, it was raining and cold (a usual story for that part of the world). I couldn’t seem to stop the windows from fogging.

I was churning through podcasts to pass the time. Somewhere along the highway, around Goulburn from memory, one of the podcasts grabbed my attention a little more forcefully than the others. I see now that this was a truly influential experience. Not because of the podcast, but rather because of the book it led me to read and the challenges it posed for me.

The point of today’s post is not to summarise the podcast, nor is it to analyse the book (I will put links to both of these things at the bottom for you). Instead, the point is to discuss a single basic idea they promote. The point of this post is to suggest that the idea below is critical when it comes to a medical education.

Do things that scare you.

The podcast led me to a book called The Flinch, written by Julien Smith. The Flinch is an uncomfortable read, it lays you bare. The words strip away excuses, they expose insecurity and a lack of readiness to abandon comfort. To quote from the first page of the book, “The book is about how to stop flinching. It’s about facing pain”.

The ‘flinch’ that Smith refers to is that innate jump at a scary circumstance. It’s the jump that gets you running away from the lion. Smith asserts that these days our flinches are over-active. That we flinch at harmless things – public speaking, exams, performing in front of your peers or your mentors. In everyday life our flinches are unnecessary and limiting. Some people are affected more than others. The Flinch preaches the need to re-train our innate flinch, to re-calibrate the set-point for a flinch to be warranted, to re-establish what things are actually ‘scary’. To do this, Smith takes us through a series of challenges. He asks us to face some fears.

Opinion: if you have an overactive flinch, taming it down is a must if you plan to make it through med school.

The situation that sticks in my head is week one of clinical teaching at our medical school. To set the scene… You are being told that this next skill is perhaps the most important thing you will do with patients within your career. The clinician emphasises that it is going to take years to get good at this skill and even then, you will make mistakes. You find out that the skill it to take a patient’s history. You think to yourself ‘Geez, how hard could that be?’. Next thing you know you are sitting in a small tutorial room with your classmates. A volunteer patient walks through the door as the tutor asks for a volunteer. FLINCH.

Heart rate starts climbing. Sweaty palms in full swing. Downward spiral of negative thoughts.

There is a fundamental question raised in Smith’s book. Why do harmless things, things like the chance for structured learning and direct feedback that I’ve described above, scare so many of us? And beyond this the book poses the challenge to us. Re-train this ‘habit’ by exposing ourselves to harmless instances of fear and we will benefit. Re-train yourself to remove unnecessary flinches.

As a medical student, fear will shelter you from opportunities, from experience, from feedback and development. Being that person who volunteers to go first provides tremendous benefits.

When facing fears starting small is the key. Smith urges us to consider facing ‘scary’ things with no possible detrimental outcome. He wants you to take a cold shower (managed almost a year of that – Canberra winter got me eventually). He wants you to smash a mug (really? a perfectly good mug? I still flinch when I think about this one). He asks you to speak to a stranger (welcome to every day in medicine for the rest of your life). He wants you to escalate these things appropriately to the point where you are more comfortable, less afraid, more confident.

I attempted to adopt these ideas, along with always having a desire to seek challenges. I did the cold showers for a stint, I smashed the mug (only once), I spoke to strangers repeatedly. I became more comfortable, less afraid, and developed more confidence. I didn’t stop there, I continue to face flinches when I see them. Often I start stripping off for a shower and shudder at the thought of a cold shower. I take this as a sign that the flinch is back and force myself into the icy water. I say yes to all things possible, regardless of a grumbling fear, a racing heart or some sweaty palms. Now when I hear a call for a volunteer I quickly call out “I’ll have a go”. Not because I’m cocky or greedy but because I feel the need to keep the flinch at bay.

I believe that keeping the flinch at bay will lead to opportunities, experience, feedback and development. I believe that we need to find things that scare us and that being brave is about finding those things, having that fear, but doing them anyway.

Be brave, it’ll be worth it.

Podcast – http://robbwolf.com/2011/12/20/the-paleo-solution-episode-111/

Book – http://raouldify.files.wordpress.com/2011/12/2011_1203-the-flinch.pdf

How to study. Effectively.

I started writing post number two as I sat outstretched in the enormity of row 23 on flight FJ915….. We were in the exit row. We were on the way back from our honeymoon.

Yep, life is pretty good sometimes.

I had a foggy head (the result of a lingering hangover from the final day efforts to sample all the wine on the list). I managed to start, and then place on pause, what will likely become three or four different blog posts in the coming weeks. Giving in to the dizzying effects of the turbulence, I vowed to write more successfully, more definitively (or maybe just manage to finish a post) when suitably caffeinated – en la mañana.

So to today’s post, a more effective and definitive post.

This is an adaptation of a short presentation I gave to a fresh-faced and eager group of medical students early in 2014. We affectionately refer to them as ‘Firsties’ and the title of the talk was ‘Firsties Formative Prep’ (aimed at their first medical school exam a few weeks – the formative). I hope to lay out in a few simple rules that I try to follow in my study. These are the rules that I’ve figured out/been taught/wished I’d started following sooner/am still trying to figure out how to do etc. They are rules that do not dictate the step by step of studying (add a comment if you want me to provide that information) and this is by no means as exhaustive list. I see merit in their application to learning medicine and hope some will suit your style.

Rule 1: Set informed goals (and do not do a single thing unless it falls under one these goals)

There is a buzz in our medical school about the concept of learning objectives, different levels of objectives, use of objectives to plan assessment items etc (and the Australian Medical Council uses these outcomes in decisions about the accreditation of our schools). I won’t go down that tangent except to say that learning objectives, for the most part, are given to us. These objectives go full circle when they are used to decide our exam questions.

To state it simply, set your goals (or write your questions – more on that soon) based directly on these objectives and if you find yourself working on things that are not encompassed in the objectives – STOP! Make a note of what you were doing and come back to it after exams.

I struggled early on when studying. I struggled mostly because the medical world is so full of cool sh^t. It’s all fascinating. I would catch myself buried in a textbook, in a chapter nowhere near the topic I intended on looking up for clarification. Do not get caught in this trap. Or if you do, acknowledge the interest, enable the fascination and then get back on track. There are quite literally hours of interesting reading that could come out of each lecture and when you add up the hundreds of lectures we sit through there is simple not enough time.

SMART goals (Specific, Measurable, Achievable, Realistic, Timely – http://en.wikipedia.org/wiki/SMART_criteria) are well known and effective so read into that if it is news to you. My point is not to lay that information out. My point is to remind you to be clever when setting your goals (base them on learning objectives and areas of weakness) and be honest with yourself about whether what you are doing is actually helping you achieve one of these goals (if not then stop).

Rule 2: Get your own routine (and be consistent, not crazy, it will pay off come stuvac)

I won’t preach to you about when to study in the day, how much time to poor into your study, when you review and revisit lectures etc etc. I have studied with a lot of different people so far and always tried to take note of how other people work. The single thing that can be distilled from all of these observations is that all people work differently. Further, all people change their strategies as they go, always looking for something more effective.

The point that I will stress here is consistency. No amount of cramming in the final week before an exam can make up understanding gained from consistent, and effective, study. Yes it will help (and I certainly still practice the 16 hour days of cramming before exams) but you cannot get the depth of understanding gained from consistent and progressive work throughout the semester. Decide a routine early on and stick to it. Assess as you go whether it is being effective. Change it if it is not. Map out the specifics as you go and tick them off once they’re done.

(A side note here for those with significant others – Medicine is all consuming. You will neglect your partner and become the inattentive person you probably made fun before UNLESS…. You communicate your plan, talk to with your partner about the upcoming busy weeks, book in date nights, put your exams on the calendar, ask for their support and encouragement, talk about what this should look like. You’ll figure out the specifics of this. It took me a long time to figure it out. Do it early. Do it honestly).

Rule 3: Question and answer ONLY (do not waste your time with summaries you will never read)

I spent the first six months of medical school writing lecture summaries that I was immensely proud of. They were detailed yet easy to understand. They had pictures and tables, they were brilliant. I spent hours writing them (on average probably two hours or so per lecture – sometime up to four hours), hoping they would set me up for effective study come exam time.

I never opened them again.

Despite being all the things mentioned above, they were simply not useful when it came to studying for exams. If I tried to open summaries and read through them I fell asleep, if I went looking for specific points I couldn’t find them. I always ended up just opening the lecture slides and reading through the more succinct (although never as clear) dot points they provided.

John in the year above me (the student we were all in awe of) put me on the right path. He preached question and answer format. For everything. This was a scary concept at first – ‘so I don’t even write a summary?’. But I took the plunge.

I dropped the summary format. I sat in lectures writing questions rather than taking notes. I went home and answered the questions rather than summarising the points. It was transformative. I realised within a few lectures that in answering my questions I got my summaries. By getting me head thinking in questions and answers it became clear what the main concepts within each lecture were. Perhaps most importantly, the two hours I had been spending summarising the lecture was cut down by half, or by two thirds, or even more.

I believe that each time you need to recall information you’ve been taught in medical school it will be in the form of a question (exam questions, questions from consultants on the wards, questions from patients). Not once will a consultant ask you to summarise a concept for them, they will grill you on details. I think it is more effective to do all your study in question and answers. I think it is more specific and more time efficient.

Rule 4: Do the uncomfortable things (effective study is more frustrating than fun)

Humans are described as creatures of comfort. We seek the comfortable in situations where we have choice. Applying this to study, when there is the choice between studying something that makes you feel good or something that makes you feel uncomfortable we will choose the former. Every single time.

The comfy topics are the ones we know. My background as an exercise physiologist means that I love muscles, I love talking about types of contraction. Holy sh&t do I get excited about anaerobic thresholds, VO2 etc etc. As a creature of comfort I would find my way to topics like this completely subconsciously. I would happily explain them to my classmates, happily review them again ‘just to be sure’. Moreover and more importantly, I would steer far away from that sick feeling I got when I opened the page to genetics, to histology, to anything to do with chemistry. Gosh do I hate chemistry. I frequently got frustrated and gave up because I did not know these things well (and still don’t). I did not know these things well cause I avoided them, I avoided their discomfort.

The uncomfortable topics are invariably the ones you need to study most.

I think I’ve made my point here. You need to police yourself. Be aware of how you respond to different topics (yes Mum I am eluding to some of the mindfulness you so love) and force yourself to work on the uncomfortable topics while not completely neglecting the feel good areas.

That’s it folks.

Blog number two done and the resolution still on track. Inevitably these rules will not suit everyone, they will likely be downright bad for some but I do I hope that some get benefit from these concepts that have delivered me safely through the first two years of medical school.