March 1997
Time marches on. Even though exams are a few months away, the nature of these exams is such that I spend a few minutes every week telling my parents how easy and almost acceptable it is to fail in Final Year. I am working on the concept that anything, if repeated enough times, becomes the gospel truth. I certainly believe it, and I am working hard on my parents too. They seem to be continuous denial, as all good parents will be. "People fail, but surely not YOU?". Sigh. The pressure of expectation.
This has been reinforced by my Orthopedic experiences and I am just grateful that Ortho is not a full fledged subject by itself.
We have, past Ortho misadventures notwithstanding, moved smoothly into our Medicine posting. This is quite a biggie and for me is the most challenging. The first problem is the history. It's all in Tamil and nowhere is the patient's history more important than in Medicine. There are basically 4 systems which we will get as our "cases". CVS (Cardiovascular) means picking up heart murmurs, taking detailed histories of chest pain, breathlessness, cough, things called PND and NYHA grading and trying to figure out what's going wrong. The usual patient has multiple heart valve problems so a quick stethoscope to the chest can only pick up an orchestra of clicks, whooshes and shhhh kind of sounds, of varying intensity and pitch. These also have to be timed with the actual stage the heart is beating in (systole or diastole) and then try to see if the patient has Atrial fibrillation (Irregularly irregular pulse, much like my irregularly irregular attendance) or if the heart is failing....and if it is Right or Left heart.
Most of the time, there are atleast 3 such sounds happening simultaneously. And if they are faint or inaudible, one can do various things like get the patient to hop in place or lean forward etc to get them to become worse and therefore louder.
One time last year, while examining a case of Mitral Stenosis, someone tapped too hard on the chest and the patient soon had a stroke. Presumably, this was due to something getting dislodged and travelling to the brain.
The RS (Respiratory System) is worse. The symptoms are similar to the CVS but the examination is more subtle. The chest shape needs to be noted, breath sounds need to be categorized as tubular, rhonchi, hollow etc and they all sound the same to me. One has to tap the chest and hear for hollow sounds or dull sounds or whatever the underlying lung sounds like.
It's done by tapping a finger with another and there is a technique to it. My fingers are congenitally bent-like a Swan Neck Deformity, and I don't know if that's the cause for my not-so-good percussion. There may be a cavity in the lungs or perhaps some fluid in the pleura, or just to screw you in exams, everything can be there in the same patient. TB is an obviously common diagnosis but as I'm learning fast, the diagnosis doesn't really matter. What matters is how well one can pick up all the signs, how well one can take a relevant history and how well one can gel all these things into something that sounds sensible.
RS is a nightmare. If I get this in the exam, I'm done.
Next is the CNS and this is where things can go haywire very fast. I am told that examination of the nervous system is like maths in that the findings are objective, always mean something and if properly done, will always lead you to the problem. I have never been great at Maths and I am only slightly better at this.
The whole examination takes ages. Start with assessing Higher functions like speech and memory, move on to examining the senses and sensations in the limbs, chest, abdomen (fine touch, coarse touch, temperature, vibration), quickly jump to assessing all the muscles and their movements and tones, ending with the cranial nerves.
This may sound simple but it all has to be done in about 30 minutes and things can get interesting when one gets a stroke patient. Sometimes, they have lost speech and cant say anything. So there is no history to take. This scenario happens fairly frequently in exams and has varying consequences. For some, it's a boon because the examination technique and findings decides everything. For others, it's a nightmare because in an already high stress exam, it's not easy performing this examination on someone who cannot say anything.
Strokes are common, all varieties, and then there are spinal cord problems where finding the level of the problem is the key. Again, the diagnosis can be very exotic, ranging from Radiation Myelitis to Leukemic Metastases to Neuropathies but it's the findings that will make or break you.
The Abdomen is where I feel most comfortable. Tapping the abdomen to look for fluid is easy but can get tricky in really fat people. (Yes, I know the irony).It's all about finding enlarged livers and spleens and masses and not so tough.
And of course, we have no idea of what system we're going to get. AND, of course, multi system problems can happen quite easily.
Just to spice it up a notch.
But.....in the exam, we will have 45 minutes to take a history, do the examination (of ALL 4 systems) AND write all of it down in detail on a case sheet which we will not be allowed to look at when presenting the case. And there can be no discrepancy between what we say and what's on the paper.
And that is what kills many people.
I'm having a hard time. I present a case to Madam AA, who is very elegant but very expressionless. I'm just not sure if what I'm saying is correct or not and her blank face is very unnerving. Dr TD is the same. It seems that in exams, he will allow you to ramble on, digging your own grave.
Dr RP's classes are conducted half in Tamil, most of the talking directed to the local Day Scholars and it's easy to lose focus and interest. He's unique and his classes can get unintentionally hilarious.
Once, reacting to a weird diagnosis made by one us, he shouts
"Doctor! Get aback"...
He adds 2 symptoms to make a diagnosis (Spleen + Amputated Limb=Polycythemia) etc and I find his classes a bit tiring.
Dr KR is a genius clinician. His classes are fantastic and the best place to learn Medicine. He appears serious, with thick glasses and has written a book on Examination technique. He, however, also has a reputation for being very "fair" in exams, which basically translates to passing if you are up to it, or just watching the sinking ship sink.
Dr AD, on the other hand, is a "gem." He is the Head, always wears a tie, mostly red in colour and is held in awe by the rest of the Dept, mostly because he is the Head. He talks fast, in a slight Bengali accent which makes all the S sounds sound like Shh..He is very encouraging ad when he asks a question, always follows it with "Yesshhh, yessshhhh, tell me, tell me...I know you know, come on yeshhh yeshhh".
However, often one does NOT know the answer and the sheer terror of being blatantly ignorant in front of the Head and a definite Final Year Examiner is a sight to behold.
The schedule is much the same. Clinics from 9 to 1, sometimes 130 and I dread my turns to present cases. I need to get over this though, and fast. We often pass the Juniors, still in the First Clinical Year, taking their first steps in Clinical Medicine and I'm glad that even though life has become much tougher, the finish line is closer.
It's a tiring posting, very intensive and also exhaustive. The subject has no end and any case discussion can end up going in any direction. One wrong finding can lead one completely off kilter and sometimes results in a fail. It is the toughest exam to pass.
The books are pretty think and the variety confuses me. Some guys like to read Harrisons, the bible of Medicine, or atleast make it a point to bring it out when people are watching. Some read Kumar and Clark or Davidson and I am particularly pissed off when people say
"But such-and such thing is better given in this book, and some of the causes are better explained in that book, or the treatment is better in this but everything else is better there..."
I can hardly read one book and at first, I am infuriated but later, I just ignore it.
Medicine is a race against time. There is simply too much to read and absorb.
The Ward leaving comes and goes I fail. Not by much, but still.
3 postings down, 5 to go.
Time marches on. Even though exams are a few months away, the nature of these exams is such that I spend a few minutes every week telling my parents how easy and almost acceptable it is to fail in Final Year. I am working on the concept that anything, if repeated enough times, becomes the gospel truth. I certainly believe it, and I am working hard on my parents too. They seem to be continuous denial, as all good parents will be. "People fail, but surely not YOU?". Sigh. The pressure of expectation.
This has been reinforced by my Orthopedic experiences and I am just grateful that Ortho is not a full fledged subject by itself.
We have, past Ortho misadventures notwithstanding, moved smoothly into our Medicine posting. This is quite a biggie and for me is the most challenging. The first problem is the history. It's all in Tamil and nowhere is the patient's history more important than in Medicine. There are basically 4 systems which we will get as our "cases". CVS (Cardiovascular) means picking up heart murmurs, taking detailed histories of chest pain, breathlessness, cough, things called PND and NYHA grading and trying to figure out what's going wrong. The usual patient has multiple heart valve problems so a quick stethoscope to the chest can only pick up an orchestra of clicks, whooshes and shhhh kind of sounds, of varying intensity and pitch. These also have to be timed with the actual stage the heart is beating in (systole or diastole) and then try to see if the patient has Atrial fibrillation (Irregularly irregular pulse, much like my irregularly irregular attendance) or if the heart is failing....and if it is Right or Left heart.
Most of the time, there are atleast 3 such sounds happening simultaneously. And if they are faint or inaudible, one can do various things like get the patient to hop in place or lean forward etc to get them to become worse and therefore louder.
One time last year, while examining a case of Mitral Stenosis, someone tapped too hard on the chest and the patient soon had a stroke. Presumably, this was due to something getting dislodged and travelling to the brain.
The RS (Respiratory System) is worse. The symptoms are similar to the CVS but the examination is more subtle. The chest shape needs to be noted, breath sounds need to be categorized as tubular, rhonchi, hollow etc and they all sound the same to me. One has to tap the chest and hear for hollow sounds or dull sounds or whatever the underlying lung sounds like.
It's done by tapping a finger with another and there is a technique to it. My fingers are congenitally bent-like a Swan Neck Deformity, and I don't know if that's the cause for my not-so-good percussion. There may be a cavity in the lungs or perhaps some fluid in the pleura, or just to screw you in exams, everything can be there in the same patient. TB is an obviously common diagnosis but as I'm learning fast, the diagnosis doesn't really matter. What matters is how well one can pick up all the signs, how well one can take a relevant history and how well one can gel all these things into something that sounds sensible.
RS is a nightmare. If I get this in the exam, I'm done.
Next is the CNS and this is where things can go haywire very fast. I am told that examination of the nervous system is like maths in that the findings are objective, always mean something and if properly done, will always lead you to the problem. I have never been great at Maths and I am only slightly better at this.
The whole examination takes ages. Start with assessing Higher functions like speech and memory, move on to examining the senses and sensations in the limbs, chest, abdomen (fine touch, coarse touch, temperature, vibration), quickly jump to assessing all the muscles and their movements and tones, ending with the cranial nerves.
This may sound simple but it all has to be done in about 30 minutes and things can get interesting when one gets a stroke patient. Sometimes, they have lost speech and cant say anything. So there is no history to take. This scenario happens fairly frequently in exams and has varying consequences. For some, it's a boon because the examination technique and findings decides everything. For others, it's a nightmare because in an already high stress exam, it's not easy performing this examination on someone who cannot say anything.
Strokes are common, all varieties, and then there are spinal cord problems where finding the level of the problem is the key. Again, the diagnosis can be very exotic, ranging from Radiation Myelitis to Leukemic Metastases to Neuropathies but it's the findings that will make or break you.
The Abdomen is where I feel most comfortable. Tapping the abdomen to look for fluid is easy but can get tricky in really fat people. (Yes, I know the irony).It's all about finding enlarged livers and spleens and masses and not so tough.
And of course, we have no idea of what system we're going to get. AND, of course, multi system problems can happen quite easily.
Just to spice it up a notch.
But.....in the exam, we will have 45 minutes to take a history, do the examination (of ALL 4 systems) AND write all of it down in detail on a case sheet which we will not be allowed to look at when presenting the case. And there can be no discrepancy between what we say and what's on the paper.
And that is what kills many people.
I'm having a hard time. I present a case to Madam AA, who is very elegant but very expressionless. I'm just not sure if what I'm saying is correct or not and her blank face is very unnerving. Dr TD is the same. It seems that in exams, he will allow you to ramble on, digging your own grave.
Dr RP's classes are conducted half in Tamil, most of the talking directed to the local Day Scholars and it's easy to lose focus and interest. He's unique and his classes can get unintentionally hilarious.
Once, reacting to a weird diagnosis made by one us, he shouts
"Doctor! Get aback"...
He adds 2 symptoms to make a diagnosis (Spleen + Amputated Limb=Polycythemia) etc and I find his classes a bit tiring.
Dr KR is a genius clinician. His classes are fantastic and the best place to learn Medicine. He appears serious, with thick glasses and has written a book on Examination technique. He, however, also has a reputation for being very "fair" in exams, which basically translates to passing if you are up to it, or just watching the sinking ship sink.
Dr AD, on the other hand, is a "gem." He is the Head, always wears a tie, mostly red in colour and is held in awe by the rest of the Dept, mostly because he is the Head. He talks fast, in a slight Bengali accent which makes all the S sounds sound like Shh..He is very encouraging ad when he asks a question, always follows it with "Yesshhh, yessshhhh, tell me, tell me...I know you know, come on yeshhh yeshhh".
However, often one does NOT know the answer and the sheer terror of being blatantly ignorant in front of the Head and a definite Final Year Examiner is a sight to behold.
The schedule is much the same. Clinics from 9 to 1, sometimes 130 and I dread my turns to present cases. I need to get over this though, and fast. We often pass the Juniors, still in the First Clinical Year, taking their first steps in Clinical Medicine and I'm glad that even though life has become much tougher, the finish line is closer.
It's a tiring posting, very intensive and also exhaustive. The subject has no end and any case discussion can end up going in any direction. One wrong finding can lead one completely off kilter and sometimes results in a fail. It is the toughest exam to pass.
The books are pretty think and the variety confuses me. Some guys like to read Harrisons, the bible of Medicine, or atleast make it a point to bring it out when people are watching. Some read Kumar and Clark or Davidson and I am particularly pissed off when people say
"But such-and such thing is better given in this book, and some of the causes are better explained in that book, or the treatment is better in this but everything else is better there..."
I can hardly read one book and at first, I am infuriated but later, I just ignore it.
Medicine is a race against time. There is simply too much to read and absorb.
The Ward leaving comes and goes I fail. Not by much, but still.
3 postings down, 5 to go.
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