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The Daily Rhino
Tuesday, November 21, 2006

F1. It's fun: Drugged up and in demand
Originally published in the November issue of Medical Student Newspaper.

WHEN I was a student, I thought I was a bit of a bum. This was predominantly because I was, in fact, a bum. On those rare occasions when Jupiter was in the House of Saturn and the Moon was waxing, I decided to show up to whatever firm I happened to be doing. A combination of my overt ineptitude and uncontrollable humming of the Rocky theme music made me feel like I was little more than a nuisance, constantly getting underfoot of the people actually working.

With the exception of some fantastic doctors I encountered, a large amount of hospital staff made students feel particularly unwelcome on their clinical attachments. Now I've got that magical 'Dr' in front of my name, I'm treated very differently. For the first time in my life, I'm in demand.

I am endlessly courted by drug reps. No matter how many times I tell them I'm not that type of boy, they continue to thrust their increasingly bizarre freebies into my alco-wiped hands. For example, I recently experienced a glorious period in my life: I didn't pay for a single lunch all week. For whilst my position in the hospital has changed since I graduated, my cheapskate tendencies have remained entirely unabated.

I revel in my free lunches, but all Medical Student Newspaper readers will know that there is nofreelunch.org.

The NoFreeLunch movement and its related anti-Big Pharma (spit) efforts have been covered extensively in the paper, so I shan't re-tread old ground other than to say that the website is thoroughly worth checking out. It has a specific section for medical students - you are identified as a key asset, after all, you have more prescribing years ahead of you than anyone else.

I was a devotee and a committed NoFreeLuncher; I wanted nothing to do with the godless, evil drug companies (spit). I made sure to give a stern lecture to my colleagues who expressed even a passing interest in picking up a free pen. So why am I now munching on free lunching? The honest answer is because I'm weak. The supplementary answer is because it's far easier to stand steadfastly against the pharmaceutical industry (spit) when you are a student.

The freebies are so diverse and relentless in their onslaught that it is nigh impossible to avoid utilising at least a pen, especially with the inordinate amounts of writing an F1 does. When a drug company offers you dinner in a restaurant so swanky that patrons are given four types of fork, it isn't easy to say no. They have free booze (now you understand).

I tell myself that I'm actually doing the anarchic thing and consuming pharmaceutical company resources by eating their food and using their pens. But for every item of branded paraphernalia I accrue, I am subjected to a few minutes of rep-chat.

They show me Fisher Price-style bar charts explaining why their drug is better than sex and everything else KILLS you slowly. I worry that no matter how hard I try not to listen before saying "yeah yeah OK, can I have a meal ticket?", some of their hard-sell has subconsciously filtered through to the prescribing centre of my brain. Indeed, observational studies have shown that promotions and interactions with reps does affect prescribing patterns.

Along with my firm-partner, Ellie, I'm trying to get a journal club up and running (mock me not, I have a CV to worry about here). As I'm sure you already know, doctors need an incentive to turn up to anything that removes them from the mess. Chiefly, food. Who is happy to provide Ellie and me with food? Those good old drug reps. What, free of charge? Nay! They want us to present a paper that just so happens to be pushing their latest pill. Funny, that. At the very least they would want to be present to leaflet attendees with 'evidence' concerning the drug they happen to be dealing.

Our grand rounds are sponsored by pharmaceutical companies, as are the weekly GP lunches. Whilst admirable American bodies such as NoFreeLunch advocate a complete embargo on sponsorship from drug companies for talks and meetings, the British NHS does not have a vast pot from which to withdraw for such events. Use of money to feed doctors when alternative sources of funding are available might be seen as irresponsible.

Comparing the profession we have chosen with others can be depressing. Those in the world of finance train for a shorter time than us and are wined and dined frequently. But the relationship they have with clients is not the same fiduciary interaction that exists between doctor and patient. A more apt comparison would be a politician and the electorate. As the Labour Party has demonstrated recently, politicians are not supposed to accept gifts from lobbyists. These are people who want to effect change in politicians' behaviour, much in the same way reps are trying to affect doctors.

Where you stand is a decision you will begin making now, while you are a student. All I can say is, as I use my Imdur optical mouse, my Bisoprolol LED mouse-mat and my Viagra wrist support (hehe), that the person able to resist any of the goodies on offer may well be a better doctor than me. But hey, I'll have cooler stuff.

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Sunday, November 05, 2006

Hinglish 1
Vaada Synopsis
Photo: Naina June Ghosh

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Pretend doctor
THE crappy articles I write for the fine, fine Medical Student Newspaper have somehow won 3 nominations for the Guardian Student Media Awards 2006 (best columnist, best features writer and best diversity writer). Don't tell anyone there's been an error until after the ceremony.

With my worrying graduation, the newspaper now has two in-house doctors with my column on F1 (the first year of work) alongside the celebrated Dr Crippen's column.

Below are my first offerings for the new academic year, first published in the October 2006 issue.

F1. It's fun.

Merely a few weeks ago I was one of you. I loved being a student. Now, dragged kicking and screaming into the world of work, I realise I know far less than I did before finals.

Medicine is one of those degrees where you are essentially the same impotent apprentice for four/five/six years and within the space of one exam result, suddenly you can prescribe morphine and cardiovert people.

The summer after finals is a glorious time - all the perks of being a doctor (i.e. telling people you are a doctor, and are thus superior to them) but none of the responsibilities. Even when starting work, you're eased into things and you have helpful SHOs and registrars to guide you away from negligence suits. But after a few beers on Saturday night, it's quite another story.

I was out with two non-medical mates, buying a pitcher. As I was paying, some bastard grabbed my pitcher and started glugging my beer. Drunk rapscallion's best defence was "I wanted a drink". I figured it wasn't the best day to get stabbed in a drunken altercation, so I walked away. Note - no cowardice was involved, only good sense. GOOD SENSE.

The story met with resounding condemnation when recounted to my two friends, Arthur and Froy, but we continued our drinking. Hours later we were leaving the pub. I saw the same thieving miscreant mounting his scooter. I said "look, there's the blighter!"

Arthur and Froy expressed yet more disgust at the beer-burglar and Froy shook his fist in the air and said "I hope he gets run down!" We had totally mislaid the fact that the chap was blind drunk.

As we walked onto the road, a sudden and almighty crash spun us around. All I could see was a helmet rolling slowly down the main road.

My first instinct was, obviously, to check to see if a head was inside. Secretly, we remembered our beer and its heinous theft.

As I was calling an ambulance I walked around the corner to see a pretty horrific sight. The rider had been thrown clear over a wall and onto a pedestrian island by a mini-van, his scooter was in quite another part of town and his left shoe was in Monsoon. A pool of blood was collecting around his head, as was a huge group of Saturday night revellers.

"I know what to do!" "Put him in the recovery position!" "Press on his cut!" They thronged.

I walked closer and then I said it. The line that I'd been dreaming about saying since I got into George's. A fortnight or so into the job and here I was with a chance to say it to a captive audience.

"Guys, guys, it's OK. I'm a doctor."

If you've read any previous Rohinplastys (so...just you Mum), you'll know nauseating arrogance is something I positively enjoy, but this may have been my apogee. That one moment made six years of debt worth it. I'm told that the rewards of helping people and saving lives make medicine worthwhile, but until I actually do any of that, the smug-factor of that one line will be the highlight of my life as an F1.

The huddle parted for me. I was Moses. Get out of my way, I'm a doctor, a doctor I tell you! Let me bask in your admiration for a bit.

Oh yeah, guy on floor. Fuck.

The glory was quickly replaced with deep, deep regret. Why did I step forward? What the hell can I do? I'm about as useful as rhubarb. Right, right…primary survey, ABC. Good, he's breathing OK and stuff. Err… "Don't move his neck" someone shouts. No help, I knew THAT one. Umm…D, disability. Shit, bugger, err…

He did turn out OK, despite a woman asking if I really was a doctor. But two vital lessons were learnt.

First, I'm not a REAL doctor yet. Further testament to my pretend-doctor status is plentiful at work, I can't prescribe drugs outside the hospital, all my clerkings are reviewed and I need to be supervised doing anything mildly fuck-upable. If you are a drunk beer-stealing scooter-driver, you better hope a passing doctor isn't a new house officer. You REALLY better hope it's not me.

The other lesson was far more important and learned not by myself, but by the lad on the floor. Deep down he knows, yes he knows, that if you steal beer, bad things happen. And karma sure is instant these days.

Relating to the dead

Ash cash. The sixty two pounds a doctor pockets every time a patient they have certified pops their clogs and is burnt to a crisp is nothing short of infamous. Known as the house officer’s privilege, it is the fund for Thursday night drinks all over the country.

A colleague working on care of the elderly has effectively gone up a banding due to the vast amounts of ash cash he rakes in. No comment on his quality as a doctor, of course. Ahem.

A complex patient passed away recently. Every doctor knew her because she was afflicted with something juniors encounter on a frequent basis, the family from hell.

On each occasion I was on ward cover, I would spend a good portion of my evening engaged in fruitless and frustrating conversations with her children. They were in complete denial that their young mother had extensive breast cancer with massive brain, lung and liver mets.

The nursing staff were no less bullied by the family and as a result the responsibility of placating them was always shifted to the on-call docs, who would be summoned repeatedly.

After a month or so of the daughter demanding to see a doctor at all hours of the night because she wanted all analgesia stopped or DNAR forms reversed, I became fairly rude and grew to intensely dislike being asked to review the patient.

I could only be disappointed with myself for coming to loathe a patient’s family, but as long as they made my life difficult by wasting my time as the bleeps piled up, I didn’t care. It is a horrible thing to hate someone just for loving their Mum.

Finally, she died.

Confirming the death of a warm, just-expired body, late at night, is an unusual experience for some.

You will find that when you confirm your first death, you convince yourself you can hear something as one rarely hears silence through a stethoscope. The embarrassing thought that a patient will reach the mortuary and suddenly perk up ensures you are extra-thorough.

I was genuinely sad that this mother-of-two had died a slow death aged 42, but relieved I would never have to meet her insane family again.

Life continued for me as normal and I did not give her another thought for several days. Until five days after her mother had expired, the problem daughter was leaving my ward at midnight.

I asked the staff nurse why she was here and she explained she had come to pray in the room in which her mother died. With a shrug of my shoulders I dismissed this as yet more odd behaviour from an odd person.

I finished my always-horrific ward cover on-call soon afterwards and went back to my digs. Out of the window I heard two foxes fighting, but when I looked out I instead saw the daughter howling with sorrow outside the hospital.

She had lost her Mum. Her Mum was younger than mine is now. It was almost 1 a.m. and she was alone. I felt overwhelmed with guilt for hating this unlucky girl and I went outside to talk to her. In yet another example of my complete inadequacy, I sat there for some time, not knowing what to say.

Maybe it helped; it probably didn’t. It would be overtly corny to suggest that now every time I write a death certificate, I do so with a sombre disposition and rueful melancholy. It is necessary to be somewhat hardened to death and dying as a doctor or medical student. But I sincerely try to put myself in the shoes of a patient’s family member.

Having said all of that, I still dread having to see an unpleasant family. Relatives can stonewall and flummox you, but corpses don’t ask awkward questions.

I treat the dead the same way I always have, but I’m slowly learning to deal with the living.

"A grave is a place where the dead are laid to await the coming of the medical student"

- Ambrose Bierce

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