Seen in psychiatry attending’s progress notes:
Book Romanian interruptor for next week’s ward round
Seen in psychiatry attending’s progress notes:
Book Romanian interruptor for next week’s ward round
Seen on the ED admissions screen:
It was a humid and cloudy day in mid-May. I was stressed out because I misjudged how long it would take me to get to the Prometric center. Luckily, I made it with plenty of time to spare. This was my first attempt taking the MCCEE (Medical Council of Canada Evaluating Exam).
My mark: 313
The exam: You start with a tutorial. There was a highlighting function that worked very, very poorly and was rather distracting/time-wasting. Once the tutorial was over, there it was. 1 out of 180 questions in the top left corner. A timer counting down from 4:00:00 on the right. There was no blocks, just question after question. There was a calculator function. No labs button (but the questions gave you normal values in the stem). 4 hours is plenty of time to get through the exam. The questions were fair. Nothing to abstract or out of the ordinary. There was something that annoyed me and I don’t know if it’s because I wrote the exam in the UK, but every time there was any mention of acetaminophen, there was paracetamol in parenthesis right next to it – each time. I don’t know if that’s because I was writing the test in Europe, where Tylenol is known as paracetamol, or whether I would have come across the same thing had I been doing the exam in Canada. Another thing that annoyed me was the highlighter function – you weren’t able to highlight a word without highlighting ALL of the text that came before it. And forget about trying to highlight two different words in a stem – disaster. Anyway, after the exam, you have time for a survey, where I would have mentioned all of the above – but my keyboard wasn’t working! I ended up clicking through it to exit out just to get it over and done with at the end.
My study prep: I bought the CanadaQBank in September for 6 months, with the initial intent on writing the exam in March. However, I wasn’t really studying and work got in the way. Before I knew it, it was February – my exam hadn’t been booked yet and I didn’t feel anywhere near ready. I decided then that I would book it for May, extend my QBank subscription, and really get cracking on it. I went through all the questions in 50Q blocks by topic in tutor mode. I started with my easiest subject (surgery) and saved my worst (medicine) for last. It took me until May to get through everything once. I made flashcards and used Dr Google (Medscape and Wikipedia) to fill in any gaps on my weaker subjects. Finally, I went through a few question sets using only the difficult questions on an untimed mode. The day before the exam, I did four sets of 45 questions in a timed mode – only to practice going through 180 questions in a test-like scenario. I’d like to say I used another resource, but I didn’t. I do think almost two years of clinical work does help though.
My advice: Think back to previous exams you’ve written and those you did well on. Some people like to read books to study. Others like to watch videos or listen to audio files. Others like to learn from question banks. I’ve always found that I learn best by doing questions. The easy ones are those I can apply to patients and medical conditions I’ve seen and treated previously. My one successful strategy is being able to apply medical knowledge to real-world scenarios. That’s where my strength came in. Also, be fluid and adaptable to what’s going on in your life. My plan to write the exam in March didn’t happen as planned, so I had to re-work a few things and re-plan my schedule because life was getting in the way. If you’re in med school, it’s a lot easier to create a study schedule and stick with it. But if you’re working or have a family or other priorities, you need to be able to adjust for them.
Everything is about trial-and-error. I’ve read through dozens of message boards and forums to try to find that one successful strategy. It’s different for everyone. I’ve previously done all of Kaplan. I’ve tried Goljan, DIT, the Pass Program – you name it. I’ve studied for school exams by reading chapter after chapter – I didn’t retain much. I’ve listened to audio files – didn’t retain much either. Most of my knowledge has come from being able to apply what I’m studying to real life scenarios. If I had understood this whilst a student, I would have put in a much greater effort during my clinical years to learn as much as I could from the patients I was seeing.
What’s next: MCCQE1 (approx $1000) and the NAC OSCE (approx $2500). I need to have done (and passed) the NAC OSCE in order to apply to CaRMS in October/November 2017. But I also want to write the QE1 around the same time to have it over and done with; and so I can stick it on my CV. It’s too late to write the NAC OSCE in November, so I will try to get the exams booked for Spring 2017. In the meantime, I’ll have a look around to develop a study schedule and see if there are any study resources that may be useful over the coming months.
So I’m due to start a family medicine residency in August – but I’m currently working in the emergency department and I LOVE this job. The hours are awful, other specialties can give me shit when referring patients, and patients often want more than what I can offer them, but I love the pace of the job and the work I do.
I’ve abandoned the thought of training in a surgical specialty because it requires a minimum of 5 more years of training (and most train for 7 years before becoming attendings). And speaking to my senior colleagues makes me realize that training is not as simple as keeping a surgical logbook and attaining specific surgical skills at different levels of training. In this country, it’s all about your tick-boxes: audits, audits, and more audits; research and publications, but not just in any journal – it must be a peer-reviewed journal; teaching, with “evidence” that you’ve taught; conference presentations and poster presentations. And you’re strewn all over the country at times. And they have almost the same requirements to get into the surgical training post as well – those who meet the tick-box requirements get in. There are no reference letters highlighting whether you’ve got the surgical skills to make it in the job. You don’t get “points” for being able to be a proficient first-assist in a laparotomy. The structure of the system is flawed.
I am now at the point where I’ll be entering general practice, and this also comes with its own set of requirements during training, one of which I’m particularly not looking forward to – reflections. Every week, a requirement is to two at least two reflections either about a patients encounter or on something you’ve learned from. Personally, I’m not one to reflect – in a blog, yes. But in a portfolio – no. Especially since I know it will be read and assessed by my supervisor. In that sense, I feel my reflections will be very superficial and I won’t be as honest as I truly feel. But, whatevs.
My other thought is what if I abandon general practice and try to jump into emergency medicine training. I’d be more satisfied with my job. But training would again be another years. The option I’m set on now is to endure the three years of general practice and then get a fellowship in emergency medicine and remain there. The options are endless. My career path is not a fluid one. The only path that’s certain for me with work is my return to Canada. My aim: return in a maximum of 3 years, if not earlier.
Way back after my first year of medical school, we were required to do a medical observership/attachment. Our school wasn’t too specific about where and in what specialty to do it, so I ended up shadowing/observing a general surgery attending in Toronto. I remember sitting in on his clinics in the beginning of the week, and scrubbing into surgery in the latter half. I was enthralled! I was excited! I’m trying to think back, and it may have very well been my first time scrubbed in the OR.
There was a peculiar thing that the surgeon would do each day as well – his secretary would print him off a patient list and we’d leave the office or OR and see patients in the hospital. Just me and him. He’d find the patient, have a brief look through the patient’s notes, pop in the patients room and say hi, find out how they’re doing. Then he’d leave and scribble a line or two in the notes. Then we were off to see the next patient.
He didn’t say much during this time, but I now realize that we were rounding on all his post-op patients. I think my perception of rounding was jaded by TV shows where an entire group of doctors goes from patient to patient presenting relevant details and the attending makes a plan while a scattered intern scribbles everything down in the patient’s notes. Where the attending asks relevant medical questions to pimp out the residents. There was none of that here.
And in reality, having a morning ward round for nearly two years now, I can still say that it’s nothing like what’s depicted on TV. Maybe it’s because I’m practicing in the UK where their system is a bit different. I’ve been on specialties that approach reviewing patients in different ways. In the ED, we gather in a seminar room every couple hours (during shift changes) to catch up on all the patients via a computer screen – who’s been seen, who’s been referred, who still needs a referral, who’s likely going home, and what the plan is for each patient. And in ED, your patient is basically your patient. A senior doctor will give their input or advice, but it’s your job to make sure all the investigations are done and checked, and a referral or discharge plan is acted on.
When I was on breast surgery, I was working under four different attendings. If one of them showed up in the morning, they only rounded on their patients; if they came at all. A lot of the times, I would round on the patients myself – check for any post op complications, check drains, make discharge decisions, write discharge letters.
When I was on acute medicine, there would normally be two ward rounds during the day, and every day it was with a different attending and a different set of patients because of the high turnover of the unit. On the opposite hand, when I was on acute geriatrics, the attending would only round on Tuesdays and Fridays, and it was up to us young residents to manage the patients every other day – mind you, there was nothing acute about the specialty because these patients were treated very quickly and then spent the next several weeks having physiotherapy and occupational therapy assessments.
When I was on Urology, a different attending led the ward round every day, and we would see all the patients under the urology team – this was probably the most problematic type of ward round because on Monday, we would have one plan in place for a patient, and the next day’s attending would make a different plan the following day.
The parts of the ward round that remain consistent between each different specialty I’ve been on include plenty of writing and creating a jobs list so that when the round was over, I’d be able to get to work with sorting out scans, X-rays, CTs, discharges. And perhaps it’s just the way the UK system works, but there hasn’t been much teaching during this time. Many times the attending tries to finish everything off before 9 to run to the OR or to clinic. A lot of the times, they’ll only see the sickest patients and then leave the senior resident to continue with all the other patients. There’s almost never any “pimping.” And when questions are asked, they’re asked usually to all residents. And a lot of the time, we’ve become so ingrained in creating a jobs list and working through those jobs for the rest of the day that we fail to make connections between our medical knowledge and its application to the patients. We forget the basics. And even worse, I feel we lack the motivation to later go on to educate ourselves on the facts we’ve missed out on.
This is why medicine involves lifelong learning. It’s simply not enough to show up to work to present a patient’s vitals and recent blood results when we can’t make the connection between why a patient in kidney failure has persistent hyperkalemia on routine bloods despite treatment. My knowledge has been somewhat refreshed after spending the last 6 months studying for the MCCEE. But since the exam, I’ve fallen back into being lazy. I come home, watch TV or waste time online, and go to sleep. It’s an easy trap to fall into, but it’ll eventually catch up and reflect in your work. I experienced that earlier in the week when dealing with a patient. So now, I’ve had that kick in the ass I needed to get back into gear.
Life is always going to be busy. You’re never going to have enough time. The important thing is to learn to manage your time wisely. Spend some of it enjoying yourself, and spend some of it educating yourself.