The last week of surgery sped by, we didn't do too much in honesty but spoke to a few patients and had our various tutorials. Most of us were talking to and examining patients around various wards to get experience for our OSCE coming up or else we went home to study. I finally made a trip to the SCGH Lyons eye cafe and had a chai latte after hearing how much everyone likes the coffees there, the chai was pretty good too complete with studies in the sun! On the last Friday Emma and I went to visit a man who was was found to have hepatic cancer and an abdominal aneurysm that was 9cm wide! I felt sorry for the man having 2 potentially life threatening conditions found at once but he was lovely to talk to and happy for us to take an interest in his new found conditions. I would have really liked to follow him and see how he was doing but from that Friday onwards we as med students were not allowed into the hospital in case we came across patients which were to be volunteers for our exams. So what do we do? We become hermits, study hermits. It is scary to think the end of our fourth year rotations have come to an end. Even more surreal was the thought that i will not be studying in Perth hospitals next year and it was starting to sink in their some big changes coming in the not too distant future.
First things first though... i need to pass end of year exams!! I have never been more scared for the OSCE (Objective structured clinical examinations) as i have for other exams! It is a whole new structure, 8 lots of 10 minutes stations with cases and patients covering medicine, surgery, infectious diseases, geriatrics, musculoskeletal and psychiatry from our 4th year rotations. Basically you need to know your stuff to think on the spot, most people say to just have fun but it is easier for them to say when they have been through it and passed!! It was hard to know what to study... just the whole years worth of learning! And i made a 180 page document with 'notes' on what could come up. Thankfully we had a week and a half of study before they started which meant we also had time to study pathology, pharmacology and infectious diseases for those who could see past OSCEs as though it wasn't the end of the world. We had a few sessions practicing examinations and case situations quizzing one another which was a great help, and then the OSCE day arrived.
I was at RPH and not having had any rotations there before i went in early to make sure i had enough time to bus, walk and find the place i was suppose to go to. Thankfully i was not the only one going in early on the bus and between 3 of us we found it quite easily :) 8am and we sat in a lecture theatre waiting and checking our names off. 8.30am and i actually started shaking! The waiting was getting to me bad! We were taken to the outpatient area, divided into 4 streams each with 8 people and taken to our areas and then doors. I was nice of them they had cups of water and lollies (snakes) between stations for those who needed a sugar hit or something to keep them going in their nervousness. We had small introductions on our doors which we had a minute to read before we went in. The stations were 10 minutes long with a whistle at 9min, you had to be out at 10min and had one minute to get to the next door and read the next intro.
My first one was medicine - cardiovascular. I had a nice gentleman lying on the bed who presented with dyspnoea and i had to do a cardiovascular examination on him. After introducing myself i nervously started the exam. From what i can remember he had an irregular pulse, central cyanosis, conjuctiva pallor, osteoarthritic changes in his hands. I could feel his apex beat 5th IC space MCV and his heart sounds i was very excite about! I remember in my first rotation in general medicine first learnign about heart murmurs, they seemed so very complex and out of this world, but now i can describe and interpret some of the common ones and hearing one of the these on this man increased my confidence! An ejection systolic murmur heard loudest in the aortic area which radiated bilaterally to the carotids.... Aortic stenosis! I was asked on systolic murmur differential diagnosis and replied with mitral regurgitation and tricuspid reguritation. I couldn't detect any basal crackles for heart failure but he did have mild peripheral oedema. I almost ran out of time and didn't take blood pressure but i felt semi confident i had passed my first one... only 7 more to go!
My next one was also medicine but this time neurology. This one was my favourite, the examiner and patient gave me a friendly smile as i walked in (a rarity in most examiners!!) and one look at my lady and i already had a differential in my mind. She had her arm in fixed flexion, no obvious facial pathology i could see but i wasn't there to do a cranial nerve examination. Her upper limb neuro exam went well even with improvisation of soft and sharp touch with a tissue and pencil with a lack of neuro tip supplies! She had hypertonia, hyper-reflexia (the most exaggerated i had seen which was exciting for me to illicit!!), reduced power and loss of most sensation and proprioception on the right limb with the left being normal. I was confident in my answer that she had upper motor neuron pathology and suggested a stroke in the middle cerebral artery region on the left and left the room with the patient saying to the examiner 'she was a good one'.... i want to remember that moment!! :)
My next 6 stations were not as smooth, i had a few extra mind blanks than i would have liked but managed to make my way through them. From medicine i moved into Surgery. I am still yet to gain confidence in reading x-rays, chest i am good with but was then faced with an abdominal x-ray. I was asked to interpret what i described as a large bowel obstruction with dilatation of the ascending and transverse colon, stated my common causes as cancer, diverticulitis and volvulus, had a mind blank but managed to revert and state the next investigations which included a 'Barium, barium, barium.... what was the second word!!' 'Barium enema' the examiner stated as he put up the next x-ray of a barium enema and i saw the 'apple core' appearance of the distal colon occluded by colon cancer. Lastly i was to write down the management of the patient which i took down the path of surgery most likely for a Hartmann's procedure - resection and stoma in the acute setting.
Across the hall i then came across peripheral vascular disease. The examination went well until in my haste i forgot to auscultate!!! Thankfully the examiner said 'anything else you would like to do? anything to do with your neck?' and i quickly listened to the mans femoral arteries and heard a lovely sounding right femoral bruit consistent with his peripheral arterial disease and weak pulses. He had a great Beurgers positive test which i initially thought was negative until very slowly his feet started going redder, and redder..... and redder, a lobster red - definitely a positive now! It was both an exam and a learning experience for me.
Geriatrics was next. I felt prepared for Geri's but for some reason i fumbled in this one. It was a simple history and assessment of a man who had presented with a fall. The examiner kept asking 'anything else you would like to ask?' and i had the horrible feeling i was missing something so obvious and started to panic! We moved onto a gait assessment and after i did the assessment the examiner showed me a way he liked to do it, a way we had never been taught, another exam that was more of a tutorial... does this mean i was failing?? I left that one deflated but was later relieved to know that he showed this way to every student every time.
One thing about these exams is the examiner has no idea how you went in the last room. So you have one minute to pick yourself up again and tell yourself you are doing well, you can do it and walk into the next room starting a fresh! Infectious diseases was next for me, no patient but a nice examiner and a scenario of a man with fevers, dyspnoea, rhinnorrhea and a few other symptoms. This was a given, pneumonia, i knew this one!! But with a little twist it was viral. I correctly stated the next investigations, interpreted the chest x-ray and stated my treatment (remember to add Tamiflu for viral!) and the 10min was up.
Musculoskeletal... i had studied upper limb, lower limb and pelvic fractures well but not x-rays of the spine!! I knew the 'patient' we were discussing had osteoporosis but for some reason had a mind blank on the obvious COMPRESSION FRACTURE in front of my eyes! I started talking about osteoarthritis of the spine but the examiner diverted my back to osteoporosis and eventually got out of me that her loss of height was due to the compression fracture in front of my eyes.... in knew this why did i not state the obvious?!? At least i got the risk factors and other questions about osteoporosis.
2 and a half weeks of full on study and exams is hard on anyone's brain! We had 4 other exams - Science and practice of medicine (that one was strange!), pathology, pharmacology and infectious diseases, and after each one it became harder and harder to tell yourself 'one less keep going' to try and switch your mind to memorise as much as you can for the next subject. The SPM exam had coloured pages and we all had to turn each page at the same time and were not allowed to turn back, they were case based scenarios which give you more information as you go along basically to see if you are on the right track with your train of thoughts and don't miss anything major or important. The exam itself cost over $1000 to sit for some reason we do not know! So when we had to wait half an hour extra half way as they ran out of multiple choice sheets it was a little humorous as though they couldn't afford them!
Emma and I had a few delirious sleep deprived moment - singing 'you got a friend in me' from Toy story, wrapping a scarf around my head and 'trick or treating' Emma at our own door, dancing on the couches in the lounge room... i will miss not having Em around for these stressful times next year!! The relief of having the exams done was amazing, on the last exam i started out reading the first multiple choice question 4 times before it sunk in what i was reading, not the best way to start an exam but it was almost funny how hard we work our brains until we cannot think straight and become delusional in the hope we can retain as much knowledge as we can! Some even say they don't want to move too fast in case their knowledge will leak out... the sad thing is most people believe it :P
It is exciting and amazing to think how much we have learnt and progressed in one year. There is still so so (so so) much we do not know, no one can know everything particularly when medicine changes everyday, but by knowing more of the common presentations, investigations and treatments, AND a few of the more obscure conditions, we really are starting to feel like junior doctors and finishing our fourth year out of six we are closer than we may realise to enter the real world of practice!
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