The Guess-work Amplification

I've always loved Viva-voce (oral) exams, I really miss them now. They not only give you a great chance to show off just how much you know, but also how well you can communicate with the examiner. No two examiners are alike, and neither are any two vivas that an examiner takes. There're so many variables involved, there's no way that one can be "totally" prepped for these exams. Not a lot of fellow med students appreciate vivas; a lot of them know the matter but are unable to formulate a differential diagnosis, argue their points etc.

Some of the wackiest situations are when the examiner starts off on a completely different path than what you have taken, now he/she expects you to not only justify why you weren't wrong, but also why the examiner could be correct. Another is when some examiner says something outlandish & grossly wrong, leaving you to correct them. It's made for some damn interesting stories over the years.

One thing remains constant in every exam though, your ability to guess & exaggerate in front of the examiner. There's a lot of slang that's used to describe this phenomenon, "Butt मारना ", "Globe मारना " etc. I know they don't make sense at all,  but they've reached a level of national acceptance in med schools! You can either wow the examiner with your special gift of nonsense or frustrate them to new heights! Like all the crap we pull in exams, its a double-edged sword, with a shit-ass barbed handle to boot! 

There was a time last year when all of us were so apprehensive of identifying a particular sign, giving a definitive diagnosis, living a rough line of treatment. We all second-guessed ourselves, confused as a hound in  a meat factory about what we were about to say. It definitely didn't help when we had to invent symptoms, signs & diagnose a patient who wasn't a classical presentation; better yet when we tried to "Globe".

Things have changed so dramatically its insane. We now give spot-diagnosis without batting an eyelid, notice signs & argue clinical findings without giving it a second thought. There's something magical about internship because you're never worried about anyone grading you, never really worried about the patient because the hierarchy above you is always around to check on what you do. Vicarious Responsiblity (Respondeat Superior) is one of the few perks in internship, meaning that if we screw up, we're not held responsible. It's given us wings & pushes us to diagnose more often, report irregular findings with greater confidence & try things that we would otherwise never have the guts to do! I wanted to leave you with a quote on how the practice of medicine revolves around an intelligent guess; but somehow I just couldn't find it. Well, here's a funnier one instead:

"The reason doctors are so dangerous is that they believe in what they are doing"

- Robert Mendelsohn

What rhymes with blood?

There once was a doctor fresh out of school,
About to enter a hospital very cruel.
He looked around the ward, totally enthused,
Not knowing he'll soon be thoroughly abused.
The residents knew how this creature would work,
With wide eyes in the shadows they'd lurk;
Hunting, searching, grabbing at the chance
To make him on their fingertips, dance.

Everyday patients would come & go,
But somehow his knowledge would never grow.
Then one day he finally decided,
He'd do no work unless he was properly guided.
He'd prod & pry & request on both knees,
"Sir, won't you teach me what you're doing, please?"
"Alright" was the reply, the resident still undecided,
He looked around & towards a patient he glided.
"Here's this patient, draw his blood", he said
The intern would rather treat the disease instead.
Fresh out of school he still jumped at the chance,
Not knowing this would end up becoming his ritual dance.

For from that morning his life would flood,
With endless, over-powering collections of blood.
Days passed by without any respite,
Still trying to overpower a small vein's might.
He knew that soon something needed to be done,
Looking at his own veins made his head spun.
He told his superiors, "Sir, Why not give it a rest?
Why we need so much blood, I cannot digest
Every morning, I bleed these men & women dry,
And, if it clots, I must give it another try"
They just laughed & handed him another list,
More blood to collect, the intern got pissed!
The patient list crushed within his fist,
And so his protest they easily dismissed.

He walked over to the door & hung up a sign:
'Without blood, urine & stool we can't make you fine.
And if you so choose to decline our request,
I love you for finally giving me some rest.
Here, the needles are not the only pricks,
Cause these doctors can be such dastardly dicks.
Soon I'll bid adieu & be out of your hair
Leaving another intern be the cause of despair'

The 'Relative' Paradox

Its been over a month since my last post, but that’s mainly because I was having my ass handed to me in my I.Med posting. Now that things are somewhat back to normal, I’m going back to the short notes I took during these past few weeks for “blog-worthy” inspiration. Here’s my first attempt:

We’re often told by successful physicians that establishing a healthy doctor-patient relationship is half the battle won. No disrespect to those much more learned than I, but the trick is to win over the relatives. I know the ‘care’ in ‘healthcare’ centres around patients, but they’re usually irritable, loud, depressed, incontinent, have a dull sense of humour, unconscious, uncooperative & did I mention incontinent? Patients do not like doctors, irrespective of the broad grins they flash during rounds. As soon as we face the next patient, there’s the usual “She didn’t even touch me today”, or “Stupid fellow keeps examining me”, “That’s it? Who’s going to ask me about my symptoms again?” & my personal favourite, “That was your senior doctor? Even the intern seemed better than her!”. 

Patients do not care about what we have to say, they’re rarely bothered. It’s the relatives that do all the questioning, get complicated tests done, get consent & manage to keep the patient from absconding from the wards. I’ve seen people smuggling tobacco, bidis, & even alcohol into the wards for their relatives. Not surprisingly, these are the fellows with liver failure, kidney disease & lung cancers. This is only to repeat that patients are often just plain stupid & want magic drugs that cure them, without changing anything else in their life.

So, the most complicated thing a physician does every day is talk to the relatives. If only our patients weren't  so serious, everyone would see the awesome comedy that plays out (Wait, was that a pun?). Even when conveying that things are out of your hand, you must look like you’re in complete control. You must use complicated terminology when speaking in vernacular languages to convey that what you’re saying is so sophisticated, there’s no other way of explaining it. Conversely, for those cases that refuse to budge from their vices, you need to create a prognosis so grim that they crap themselves before you can utter “adult diaper”. Case in point - a man with severe alcoholic liver damage being discharged after he's relatively stable:

Patient: Sir, thank you for all the help, I am feeling great. I hope I will stay this way

Doctor: Stay this way? Feeling great? Do you know how much damage your alcohol has caused? How much difficulty we had in treating you?

Patient: What's wrong then?

Doctor: Everything! Your liver's fried, there's nothing I can do apart from giving you my own liver, which I won't. Your liver's going to rot slowly if you don't drink & you'll die quicker if you do.

Now, the resident did what was right, but without proper counselling who's to say that the patient won't drink away his stress *again*

I’ve found that you can broadly classify doctor-relative interactions into two distinct groups:

1. The secretive doctor & over-enthusiastic relative: This is the most common sight in our hospitals. Residents are overly guarded about not just the diagnosis, but also patient prognosis, the cost of tests that need to be done & sometimes even about who’s actually treating the patient. Everyone wants to be top-dog. They’re usually all bark and no bite! 
2. The over-informative doctor & dumbfounded relative:These guys will spend hours explaining rare procedures, disease etiopathogenesis, drug dynamics, prognostic indicators to the relatives, often unsuccessfully. At the end of this awesome conversation the relative innocently asks, “But what are we supposed to do now?” We quietly hand them a form & set of instructions for tests (after slapping our foreheads). These physicians usually have a successful private practice with a long waiting list for appointments or have studied abroad for variable periods of time. While they’re spending precious minutes away, the residents are usually grinding their teeth or trying to telekinetically blow their senior’s head up! Example below (just imagine they're doctors, not physicists):