The First 6 Months – Em Dwight

Em Dwight is the other amazing house officers joining the blog this year. She’s currently based at Capital & Coast DHB, and has interests in public health, primary care, and palliative medicine.

The First 6 Months

When I started medical school I envisaged that by the time I had completed 6 years of university that I would know the answers to most, if not all, of the questions that would be thrown at me as a doctor. Either I had the complete wrong approach to med school, or knowing everything was simply not the point. I’ll be honest, when I started as a house surgeon I had to look up almost all of the doses of the medications that I was prescribing, broke into a sweat anytime I was asked me to put an IV line in (literally), and was still as prone to awkward situations as ever (yup, a medical degree sure as heck doesn’t help with that). Somehow, despite my feelings of incompetency I have been asked to share a few of my experiences and reflections with you as a PGY1.

There have been times in my year where I have had to just laugh at myself. As I have already alluded to, IV lines were still a challenge by the time that I graduated. Someone advised me once to assess all the options and make a plan A and B before putting a line in. On one particular day I simply couldn’t find a viable option in someone’s upper limbs, so trying to be as smooth as possible I started lifting the bottom of the sheets while explaining that I was going to look for a vein in her feet. It was as the patient was saying “you may have some trouble, dear”, that I realised that she was a double amputee. This story is made all the worse by the fact that later in the same week I tried to look for pulses in somebody with a orthotic limb. These situations really blow your cover when you’re trying to convince the world that you know what you’re doing.

Something strange definitely happens between that night of being a TI and the day in which you become a house surgeon. Suddenly you are expected to know a lot about things you certainly didn’t have to consider at med school, and expect to come up with an answer. The most perplexing example of this are the nurses who kept little pottles of poo aside for me to look at, even though they could describe it on the bristol stool chart. It’s always phrased in such a way that’s too intriguing to deny, “I’ve never seen anything like it, it’s like she’s eaten little bits of paper”, or my personal favourite “it’s like that rhubarb on top of the puhoi valley yoghurt, do you know the one?”. I’m never quite sure what to say or do in these situations but to thank the nurse for being so thoughtful, before having to evacuate the sluice room at pace.

One of the most heart-warming things about this year has been the very human interactions you share with your patients, whether it’s laughing with them, empathizing with their suffering, or simply listening to what matters to them. Don’t ever underestimate the effect that small gestures can have, even as a student. I remember as a TI being in a resus situation with a woman who was having a postpartum bleed. There was a huge rush to get her to theatre, and in this flurry of activity it was easy to forget that at the centre of it there was a woman who was scared and felt very alone as she was wheeled away from her partner and new baby. Once I was sure there was nothing I could do to help from a medical perspective, I simply held the patient’s hand as she was put under general anaesthetic. On the ward round the following morning she pointed me out from the back of the ward round and thanked me for that reassuring gesture, even though I had very little to do with the operation that had saved her life. Those human moments are the part that make those long hours worth it, but it’s very easy to forget that or even overlook these opportunities, when you’re snowed under piles of paperwork.

The thing that is probably hardest to convey before you face it yourself is the sense of responsibility for others that you must carry when you become a doctor. It’s all well and good to talk about this in an abstract way before you graduate, but can become quite burdensome when mistakes occur. The first time I became really aware of this was when an immunocompromised patient was brought into hospital for a interventional radiological procedure. Due to hospital policy, I was the only doctor to see her prior to having the procedure to check her bloods and examine her heart and lungs before she went ahead. As a result of an oversight on my part this patient underwent the procedure without receiving prophylactic antibiotics, which she really should have had. I felt terrible when I realised this, and the nursing staff had already told the patient about the mistake before I had an opportunity to explain the situation myself. Luckily in this instance, I had developed good rapport with the patient and her partner beforehand, and safety-netted by ensuring they had good information about what signs of infection to look for. I would be lying if I said that I didn’t find that situation difficult. Here’s the thing, life isn’t perfect, and you shouldn’t expect to get it right all the time (especially as a first year doctor). That voice of reason has become a little clearer in my mind over time. Now if I pick up on my own mistakes, or even if others do, it doesn’t feel so much like a personal affront but far more like a learning point for next time I encounter a similar situation.

Something that really helps share around that sense of responsibility is having collegial support. Support can come from all sorts of places. I was on a long day with one of my colleagues when she was asked to complete her first death certificate. I hadn’t completed one either yet, but certainly knew it could be a good time to offer some moral support. With the family around we had to pretend like we knew what we were doing, but it certainly took the pressure off as I made small talk with the family as my friend examined the patient. One of the first times I personally had to fill in a death certificate it had taken me a wee bit of time to get there, and for some reason no one was in the room with that patient. To be honest, that gave me the creeps at that particular stage, so I went and grabbed one of the friendly nurses on the ward to come with me. She laughed pretty hard at me for my response to a dead body as preparing bodies for the morgue is one of the jobs that nurses frequently have to complete on their own, but was very supportive nonetheless. The thing is, your colleagues (no matter how far up the chain they are) should be looking out for you through PGY1 and be prepared to support or encourage you. No matter how silly people make you feel for asking TONNES of questions when you start your job, rest assured that it is far better to be safe than sorry and that your patients will thank you for it. As the year goes on you will find that you have fewer creases to iron out and much more capacity to step up when required, and hopefully not just to sign death certificates either.

I know I’m not alone when I say that one of the most rewarding aspects of PGY1 has been watching my skill-set expand and my confidence growing in situations I could never have confidently handled at the beginning of the year. Just last week I managed to refer a patient to ICU twice, when he really needed care that couldn’t be provided on the ward. All sorts of skills had to come to the fore, including advocacy for the patient by talking to a particularly scary ICU consultant, knowing what investigations were going to aid decision making, and which actions were going to be life-preserving. Despite the fact I worked from 7am-8pm on both days that this happened, I walked away knowing that my best had been good enough, and that I was getting better at my job.

Wellbeing:

NZMSA wellbeing month and odd-socks-for-docs day serve as timely reminders to discuss the well-being of doctors. Despite the fact that our hippocratic oath has changed to us pledging that we will look after their own wellbeing as well as our patients’ it’s easy to see that there is immense pressure to put patients’ health before our own. In the last six months I have fallen asleep in my clothes with my lights on a number of times, and had take-aways far more than I would advise my patients to. It’s fair to say that our hours alone can be absolutely exhausting, let alone the confronting situations we can be faced with on a daily basis. Luckily there are a bunch of ways that we can keep ourselves well, such as connecting with friends, having hobbies, exercising, and eating well. Even more fortunately, when things are not-so-hot, there are more than a few places to go.

First things first, I cannot reiterate the importance of having a GP that you can trust. Although qualifying with a whole bunch of brand new medical practitioners can mean that you have access to prescribed medication for free, it’s important to have someone that is able to see you through an objective professional lens. Especially when you’re moving to a new place for work this can fall to the bottom of the priority list so be proactive, find out who’s around, and sign up before you even need to make an appointment.

Going to a psychologist can be expensive, but organizations like the Employee Assistance Programme and MPS/MAS have teamed together so that we can access psychologists for FREE. There are details about EAP and the MPS/MAS counselling schemes on their respective websites.

Within the walls of the hospital, there are a number of people who may be good to talk to. All PGY1’s and PGY2’s are assigned both a clinical and educational supervisor, which can be a good place to start. RMO units often have their ears to the ground and would be able to point you in the right direction. Additionally, hospitals have occupational health units who will also have good advice if you’re facing mental or physical challenges that could be affecting your ability to work. If all else fails, talking to a trusted colleague can be immensely helpful.

On top of all of this, ensure that you have booked in plenty of leave in advance (you get thirty working days as a PGY1- space it out evenly!!). Also, be aware that you are entitled to 30 paid sick-days a year. Remember, there is no such thing as stress leave, there is only such a thing as sick leave. If you don’t feel up to doing your job and just need a rest no matter the reason, it’s really important that you do so.

Most importantly, if things are not going well for you know that it’s not your fault, and that you are not alone. Many of us have faced our own health issues or grappled with burn out. The best thing to do if you are not well, or heading in that direction, is to speak up. There are so many people who are around that care, understand the pressure associated with our careers, and genuinely want to help. If your colleagues reach out to you, be that safe space for them and equip yourself with the knowledge will help them to get the professional help they need, while you continue to be that supportive friend without burning out yourself.

That essentially summarises my thoughts on the first six months. I apologise that it took me the whole six months to put together my first post, but assure you the next one won’t be far away!

-Em