Merry Christmas Everyone
Here's hoping everyone has a wonderful and safe holiday season; that you get to enjoy time with people you care about and share joy with all of humanity.

Christmas is coming
We have our tree up and decorated and my husband has pulled out his impressive collection of Christmas carol CDs. So the holiday season is well upon us, irrespective of the fact that we have not yet started the gift hunting or made a card list. As with most things in my life, this is waiting for the completion of our present course and the latest round of exams.

I am having mixed feelings about this holiday. I am very much looking forward to the break. It will be the only one we have until X-mas 2008 and (so far) our social schedule is under control. There will, or course, be the frantic effort to catch up with friends and all the chores we have been all but ignoring but I should still have a little extra time.

So what is the problem? right?

Extra time is a med student's (at least this med student's) greatest enemy. As soon as there is a space in my schedule I think of all sorts of things to fill it with, re-over-commit myself and end up feeling like a failure when I can't get everything crossed off my to-do list. So far, in my 5 days free I have already scheduled 2 days of shadowing, promised to start cleaning out the basement and resolved to get ahead on a research project; this on top of Christmas catchup and chores I mentioned above. I will also, inevitably, spend a morning or two sleeping in, because I have earned it gosh darn it!

So I am setting myself up for regret. My Christmas hang over probably won't have anything to do with eggnog, too many trips to the goodies table or my VISA bill, but instead will live on as a list of unachieved goals that will hang around for a couple months until I finally give up.

What's my pathology
Any time I do a personality test, whether it is that introverted/extroverted/feeling/reasoning test (what is it called?) or a "Are you a bitch or a pushover?" test from a magazine, I always end up somewhere really near the middle. Right in the middle of the square or under the "you know how to make your feelings know without pissing off your coworkers" category. I used to think that it was because I was balanced and mature. Now I am not too sure.

I am starting to think that I fall in the middle because it is the average of a bimodal distribution. I am pulled by two extremes of my personality. Sometimes I wish I was reading the complete works of Shakespeare aloud on the bus. But at the same time I wish I was sensible enough to drink 8 glasses of water and go to the gym for an hour every day. In the end I am neither as eccentric or as practical as I would like to be. I am somewhere right in the middle.

One of our second year courses requires that we do 40 hours of clinical experience and write about some of the cases we see. I chose to do one of my clinical experiences in rural emergency
so I spent this last weekend in a rural emergency. It was great experience. I hesitate to call it fun, but it really was. The town is pretty small but they have a pretty big catchment area so everything from croup to motor vehicle accidents come in on the weekend.

I arrived at the hospital on Friday evening to pick up a key to the student housing. The emergency was pretty quiet at that time so I went to get settled in and find some dinner. When I arrived at the hospital the next morning the big talk was all about a case that came in at about 11pm. Patient came in GCS4, blown pupil, aspirating vomit; with no known cause. And I guess things got worse from there. They had 4 doctors, a resident, a med student, 3 ambulance teams and 4 nurses involved.

I was really jealous. If only I had been there a few hours later.

Usually I can honestly say that I would never wish anything bad to happen just for my own learning sake. But I do really wish I had been there. I think the reason is that the patient has died in every real code I have been involved in. I am about 0 for 5 now. This guy was about as bad as they come and last I heard he was stabilized in ICU in the big city. I guess I want the rush of feeling like I really helped save a life. It may be horrible and selfish but I want someone on the brink to come back for me.

The arrival of Halloween (and Christmas)

I started noticing this week that I am waking up, stepping on the train, walking into the medical faculty, leaving the faculty and coming home, all in near or complete darkness. I am a child of my environment, and this annual inevitability always gets me down. To counter my drop in sunlight induced serotonin I have increased my caffeine intake and returned to yoga. The sum of these factors leaves me tired, jittery and stiff this morning.

Yoga was at our new and shiny fitness facility at the health centre last night. As I left through the large atrium that connects the old and new buildings, I noticed a fluttering, flying animal swooping through the atrium. Sparrows are pretty common self-imposed indoor aviators, but this was larger and creepier. It was a rather angry bat. I thought it was fitting for the season.

This morning I woke again feeling like I had just returned from a trans-oceanic flight and should be asleep for another three hours. After dragging myself through the regular morning routine and checking the temperature (1 degree Celsius; not bad) I stepped outside. Everything was covered in crusty white snow. Merry winter!

I managed to get though Course 5. Course 5 is largely neuro and I have completed a Masters in neuroscience. You might think that this would put me at an advantage, and it probably did. Unfortunately it also gave me a false sense of security. My thesis was on learning and memory, which has almost nothing to do with the neurological diseases we learn about. Three days of studying after skipping most of the lectures, was not enough to feel comfortable with the final exam. Apparently I picked up more than I thought hanging around neuro labs for two years. I passed with no problem.

Now we are in Course 6 - Child and Women's health. A very different course from Neuro and aging. The course is run different, the patients are different, the health care workers are different, the attitude is different. But the most interesting difference to me is how much more opinions, and I would even say politics, play into this course.

All medicine has some aspect of "art" and we can't base everything on evidence, partly because we just don't know enough and partly because we are dealing with individual human beings and each one is unique. But I find it intriguing how often people (everyone from parents, to prenatal course instructors to doctors) argue their medical points about pregnancy and babies based on feelings or their own personal expectations. Maybe it is because everyone seems to have some. You rarely find someone who will tell you "I think you should have a stroke like this", but just about everyone will tell you how they think you should have a baby. And how you are suppose to feel about it.

Of course being pregnant (or being a baby for that matter) isn't a disease. A pregnant lady isn't sick or injured, but she isn't "normal" either. It is an extraordinary thing that happens everyday. It's a cliche but it is a common place miracle; not something you can say about a lot of other areas of medicine.

I am well into the new year. In fact our first big test is bearing down on me with a vengeance. But if that was all I had to worry about I would be happy. We recently received the form to choose our schedules for clerkship. I was pretty proud of myself for narrowing down my prospective specialties to just three (emergency, neurology and internal), until I started to contemplate the possible streams for clerkship.

With only 7 months of clerkship before they cut off our academic records for CARMs applications, strategies to get time in chosen fields but also look good during that time, are high on our minds. And, as they like to remind us as often as possible, our class is much larger than the class ahead of us. This is expected to limit our choices and inevitably lead to disappointment for many. (I am in the combined MD/graduate program so my place in the medical class was held for a year. This refrain of constrained resources particularly raises my ire. If they were going to raise the class size why didn't they make sure they had the capabilities to train everyone first. Instead we get 'your class is much bigger', as if this would explain our compromised education. Gahh!)

I am considering letting emergency slip to a distant third just to dial down the stress intensity. I think I am already well placed for either internal or neuro. I feel very behind for making myself competitive for an emerg spot even though I have done some shadowing, a summer elective (in Nepal) and started a research project in emergency.

There is much to consider and only a week to weigh it. I probably shouldn't devote too much energy to it, though. Since my 'class is much bigger than the class ahead' I probably won't get my choices anyways. I should leave it to fate.

I have finished my medical elective in Nepal. Two more days and I will back on Canadian terra firma. Four weeks went by fast but it has definitely been long enough. I spent three of my four weeks in the emergency department.

Though it is not currently a suggestion that comes up very often, small service charges have previously been proposed in Canada to help solve the problem of our stretched-to-the-limit health services. The theory being that a nominal fee will keep people from going to the doctor unnecessarily and will prompt them to seek out the most appropriate type of healthcare, for example not go to the emergency room when it could wait for a visit to the GP the next day. I have always been opposed, almost reflexively, to this idea. The idea of reaching for your wallet when you get to the doctor's office feels wrong and unCanadian. My experience in Nepal, where people do just that, has demonstrated for me why, even small payments for access to healthcare, are unjustifiable on every level.

The hospital I in which I was located is a not-for-profit hospital in the Kathmandu valley. Because it is a well-respected hospital and the fees are less than many other places, they see many of the poorer people in the area. However, it is in the Kathmandu valley so even the poor people here are better off than others in the remote areas. In the emergency department I saw largely three types of people. The first category were people who had some dramatic acute condition; traffic collisions, workplace accidents, MIs. These people come in and are treated because it is a matter of life and death. If they, or their families, can't pay, they are referred to social work and their fees are waived.

The second group is people that have the money. The fees are low enough that they will make little or no difference in their lifestyle. A chest x-ray is about $3, the price of a nice lunch in a restaurant, so it is no big deal. These are the people that come in when their 2 year old has a low-grade fever and the sniffles for a day; the teenage girl who comes in with menstrual cramps for the past hour. I am not saying that these people do not deserve healthcare, but the emergency room is not the place for it (I believe I mentioned it is cholera season here and the same number of staff has to take care of an extra 20 beds.) However, most of these people seem to have the opinion that they are entitled to complete and immediate attention. It is unusual for someone to wait longer than 30 minutes to see a doctor and if they do there is angry complaining and threats (which I was told are sometimes carried out). In Canada people often wait much longer and, while they are far from happy about it, they accept that the doctors are working away with patients that may be sicker than they are. This type of explanation carries no weight in the hospital I was at. I don't think this difference is due to Canadian politeness or some defect in the Nepali character. I think a big thing that contributes to the outrage from Nepali patients is the cash they handed over to get in the door. The fact that they paid for service means they want to be served and served now. Moreover, they have no compunction in demanding tests or particular treatments. Why not? They are paying for them. It doesn't matter that the chest x-ray for their 2 year old is exposing them to unnecessary radiation or the antibiotics will do them no good, not to mention that they are taking up more of the doctor’s time.

The third category of patients is those that come in because they really really have to. That $3 could be three (or more) days of income for their entire family and they may have to travel a large (i.e. expensive) distance to even get to the hospital. There is an increase in morbidity and mortality from this delay in treatment that only increases the burden on underprivileged families. They have now lost earning potential, especially in the case of long-term disability. But another consequence that I found particularly discouraging is how this emphasizes all other inequalities in society as well. Gender is a big one. Kids too. The sickest cholera patients I saw, the ones that looked like dried up skeletons in renal failure needing an extra dose of luck along with an IV, were young girls from poor families. It seemed to me that people would wait longer to bring in their sick daughters than their sick sons. In economic terms sons are worth more and so it makes sense, on a certain level, that they would be more willing to make the investment. I don't mean to imply that these families are callous or calculating. They are faced with impossible decisions and it is the girls that suffer the most. And don't forget, the people I saw were the ones that made it to the hospital. There are many more that aren't even able to make the choice because they live too far or have too few resources.

It is true that Nepali society is much more stratified than Canadian. The difference between poor and 'middle class' is astronomical. But with wait times and the centralization of services, there are already a number of obstacles to access in Canada as well. There are plenty of families where it is a challenge to make the paycheck stretch across a month of groceries and any extra expenses required sacrifices somewhere else. Putting up any more obstacles for those people disadvantages the most vulnerable and that would as reprehensible in Canada as it is here in Nepal.

Another week of elective has passed. Well really half week if you take out the two and a half days that my husband and I spent learning about GI complaints from the patient's perspective. With a little time, a lot of water and some help from azythromycin we are back on track.

Last "weekend" (I have been taking Friday and Saturday off though Saturday is the only actual holiday day here) we set out on an excursion through the country side. I have developed a bit of a reputation with my husband for leading him on, what he refers to as "death marches", when we are vacationing. I thought I was prepared with my lonely planet map and description but we still ended up on an uncertain path with a mini-scramble up a steep hill to a nearly un-named town. Eventually we made it to the appropriate destination. He had said he wanted to venture off the beaten track.

While I am a bit of a blonde-haired, blue-eyed anomaly in the urban Patan, I am a near alien walking through the more rural towns a short 45 minute walk away, especially those with no real road to them. People are pretty friendly after a moment of open-mouthed staring. But a person can get used to just about anything, even being a two person parade. I thought I was doing pretty good getting used to the staring, the noise, the crowds, the garbage, the pollution and the lack of order here until Monday afternoon when my husband and I both came down with diarrhea, fever with chills (really bad for him; not too bad for me) and vomiting (just me). The result of some unidentified gastric transgression we had committed the Saturday before no doubt. Nothing makes you homesick like actually being sick.

But I was back at work by Thursday and, feeling a little bit of med student guilt, took today (Friday) off for another excursion). Hopefully this one won't make us pay the same physical price. We had a really good day visiting the Swayabhunath stupa (also called Monkey temple), the National Museum (interesting art, creepy taxidermy and lots of weapons) and then walking into Thamel in Kathmandu. My husband booked a trip out to Chitwan National Park to hopefully see some nature (other than stray dogs and crows).

I just finished my first week in the Emergency department. I am not really sure how I feel about my day today... I don't know if I was prepared to see so many people die in one morning.

Maybe this is an odd thing to say, coming from a medical student. Death is probably as much a part of medicine as the living, but I must have been expecting this death to come in smaller doses. It was really hot today; combined with it being 'cholera season' and a few chronic illnesses in some susceptible people it was a rough one.

My husband is coming tomorrow so I am taking tomorrow and Saturday (the regular holiday day) off.

I started at the hospital today. It was wholely overwhelming, but strangely not as much as I anticipated. Since I still find all my clinical encounters overwhelming this wasn't too much different. So far I would say the biggest difference from the emergency expereince I have had so far is that everyone gets less space. As in the beds are really close together. Everything is done in english (orders, charts, etc) except the talking, which, at this point is probably shielding me somewhat. I have been studying the phrase book but I still haven't made it much past namaste and hajur. I attached myself to a first year resident (I can't tell how pleased she was about that) and she was great. All of the residents there were very helpful, if a little suspitious that I was just finished first year, or that there was such thing as a three year medicine program. I learned how to take my own ECG and do a pelvic exam. I saw some regular stuff like cystitis, COPD and pneumonia but also mumps, a partial miscarriage, rat poisoning and cholera. (That is probably the part where I wish I hadn't given my mother this address. It is all good mom, I am being careful.)

I am now a week into my vacation/medical elective in Asia. It has been a whirl wind up to now. I have started to settle in the Guesthouse that I will be staying at for the next month in Nepal, but I don't think the whirl wind is about to stop anytime soon.

So far my husband and I landed in Bangkok for the vacation part of my time. We went to the grand palace and a couple Wats, got Thai massages (I think this was my husband's favorite part), took a train (and bus and long boat) to Railay beach in Krabi, enjoyed some sun, explored some caves, and flew back to Bankok. We then parted ways and I flew to Nepal.

I am not sure how to describe Nepal so far. I landed at the airport and, after a bit of confusion about my name, found the driver to the guest house. The drive to the guest house was more than chaotic. There seem to be no rules, which seems to be a bit like Nepal in general. Everyone is really nice and seems to be getting where they are going, but with no apparent order. the guide book is not wrong when they say things (sights, sounds, smells) are a bit overwhelming at first.

But my room at the guesthouse is great. Surrounded by trees with a roof top patio and a school on one side. Fairly quiet except for the kids playing during the day and a wedding brass band that played last evening. I am starting to find my way around and really starting to enjoy it here (all 24hrs that I have been here so far). I am going to go exploring a little today and find my way to Patan Hospital where I start my elective tomorrow. All the best.

It has been awhile.

Not that I haven't had plenty of things to rant about but it is just that time of year. Fatigue and impatience is running high and I am certainly not immune. We are down to less than three weeks until we are released to electives. There is, of course, all the year end projects and deadlines along with the regular course and preparing for the 'summer'. To illustrate some of the frustration: Last week, after having Monday off for Victoria day, we had 8hrs of lecture on both Wednesday and Thursday and then, at an extra lecture scheduled for lunch time on Friday we got notice of a deadline that had past a week before. I can't think of a better way to stress out a bunch of tired med students than to tell them that they are already behind before they even started.

We received another reminder of the deadlines this morning. So, aside from my other work, I have added 'invent time machine' to my to do list.

It is only Tuesday but I am already sick of this week. Aside from my rapidly decreasing patience, I think I am actually sick; one of those slow irritating colds that make you tired and achey and last for ages. That or my med-student hypochondria has started to manifest in actual symptoms now.

Yesterday was a more eventful than average Monday. It was well summed up with my bike ride home. If you haven't been on the bike paths near downtown at rush hour, you might be surprised at the level of traffic that can be achieved with purely human-powered transport. The path is quite wide but with the walkers, joggers, bikers and roller bladers it turns into a exercise highway. There is even a yellow line down the middle for lanes. I was just west of downtown when I was coming up on a walker. I ran my bell and swerved to go around when I came across another walker coming right at me IN THE WRONG LANE. I swerved around her, just barely, but as I passed she shouted "Bitch" and tried to spit on me. I will assume that she was British, or perhaps from another island country where they drive on the left. But I was still a little upset with the whole encounter. This led me to wonder why it bothered me so much. Nothing really bad happened, there was no crash and I didn't even catch the loogie. So what if she was angry? She was totally in the wrong and there was nothing else I could have done. I guess it bothers me that you can be doing everything right and still get hated and spat on. This is probably a lesson that I should have learned by now. But, like I said, nothing really bad happened so I will just count my blessings and go on thinking that there is some meaning in following the rules and doing what you think is right.

We finished our first OSCE-style exams today. I wasn't even out of the room (sometimes even as the words were leaving my mouth) before I was mentally kicking myself in the rear for my own stupidity. Needless to say I wasn't very happy with my performance. I think I at least came off as a kind, caring, reasonable human being, if entirely clueless. I blame the endless training to perform well on multiple choice tests. If you give me the option of the right answer I can almost always pick it. I just can't pull it out of the nether reaches of my stress-addled brain when it is actually important.

Most of the unergraduate students at my school are now finishing up their final exams and moving on to their summer activities. Having worked and then done graduate school, I am used to year long schooling. (Our medical school has class until mid-June and we start up again at the beginning of August.) But it is still hard to concentrate with the weather (finally) getting nicer and the sun shining. To make it worse, all the year long classes are coming to an end. So we have exams without the knowledge that we will be free to enjoy the patios soon.

All of the things that sit at the top of my to-do list are things that I really don't have any motivation to do. I have found myself reading physiology just to procrastinate stuff I find even more distasteful. So I have started setting things up so that I am forced into deadlines. Like scheduling meetings I need to complete things for or setting up equipment to make myself do experiments in the lab. This has just led to another problem. After even a short time doing only things that I really have to do, I am starting to get resentful and even more unmotivated. In an attempt to prop up my waning enthusiasm for medical school I have made another push to schedule some shadowing. I always feel more hopeful about my new career in medicine after spending a few hours actually talking to patients. While a good idea in theory, scheduling all these extra things is just going to lead to a huge pressure on what little time I have left to finish all those other things I need to do.

So should I buckle down and put real effort into the things I need to do at the expense of my good mood? Or should I do the things I really like to do at the expense of my academics?

When I put it that way it really isn't even a question. I am going to go and call a couple more doctors right now.

Another systems course down; four more to go. The cardio/resp exam has come and gone and I actually did remarkably well. (The preceding sentence is meant to portray shock, not pride.) I am not sure where the last course got away from me but, with about 3 weeks left in the course, I started feeling like the heart and lungs were some sort of alien forces outside my understanding, outside my control, outside this world. Beta-blockers and agonists are my version of Jedi knights.

We have now started renal. So far I have the tubes and ions in hand, but I don't know how long that will last. I have planned my summer elective in Nepal over our exam rewrites (unavoidable given our schedule) so I have to pass this next course. Hopefully that will keep me motivated. My husband has managed to get 4 weeks off during his busiest time so he can join me. So if I fail and wreck all my plans I am also wrecking his plans for the only major vacation we will be able to have together for the next many years.

Seems hard to believe that we will be off to clerkship in less than a year. The fact that I may be responsible for patients' care is not causing me as much stress as the fact that I have made no progress towards choosing a specialty. Just about everything we have taken so far has interested me. I try to count this a positive because I think I could be happy in many different areas. But it is not helping to narrow things down.

Two days away from the next big test so, of course, I was looking for something to distract me. It was sunny for a few minutes this afternoon between the hail and the rain so I went for a walk. Springtime (which always comes with a few false starts around here) smells like wet clay and melting dog sh*t in my neighborhood. There is construction on just about every block so I zigzagged my way downtown past all the blockades. I guess I am getting a little nostalgic. The chances are good that we will have to move soon (most likely right around when I am going on elective to Nepal; great timing). After living here for 8 years I am going to miss the park and the restaurants and the people that I am used to seeing. It is funny that, as a teenager, I was so excited to move away from my small hometown to 'the big city' so that I wouldn't be constantly surrounded by the same people. After more than an decade in the 'big city' I find it comforting that I keep running into all the same people. I see the the people that I know from folk fest volunteering at concerts, neighbors at the coffee shop and people from school downtown. I even know who the regular panhandlers and prostitutes are and who is new to town. I guess it is home.

I spent the morning looking at hearts in the anatomy lab. I was again struck by the paradoxes of the human body. It is so beautiful and intricate and at the same time so crude and mechanical. It is the same thing with disease. I have seen patients with metastatic cancer throughout their body. All the organs invaded, slowly shutting down but still hanging on, sustaining life. And then the next person will have a clot travel to one particular sensitive spot or have a plaque in their heart rupture and they die suddenly, without any warning. I guess that explains why medicine can be so fascinating and gross at the same time.