Those in Australian Med School circles may be familiar with the current project and surrounding controversy at the University of Queensland: Med Students writing their own exam questions.

Dean of the School of Medicine (SOM), Prof. Wilkinson has promised both first- and second- year students that a quarter of the marks for their end-of-year exam will be student generated. This has been met by both skepticism and enthusiasm, in what I'd suggest as fairly equal measures from within the school, and markedly skeptical feeling from the greater medical community. Bastion of conservative journalism, The Australian, recently published this article, espousing the ridiculousness of it all.

Having 'volunteered' as a guinea-pig for this project, I'm going to throw in my two cents. I am (surprisingly) for this idea. There are two major pieces to this puzzle. Firstly, where does the SOM get its existing questions from? And, secondly; How the hell would students know how to write a half-decent exam question?

As Head of Years 1 & 2 in the MBBS programme, Dr Vaughn Kippers is well known to students for his 'Examination Review Sessions'. These involve a few statistics about how many students have aced the exam and other such nonsense. Invariably, questions are asked regarding specific questions, and the reply is along these lines;

"At UQ we are members of an international consortium of Medical Schools with access to an assessment database. Each year we must contribute a number of questions into this database in order to maintain our membership. Access to this database is held on one computer only somewhere in the depths of the medical school. We are also under strict terms that prevent us from releasing questions from this database to you. For this reason, we cannot provide you with past exam papers or model answers and cannot specifically discuss questions in such open settings as this. If you find that when you review your paper in person, there is a discrepancy with the adding of marks or similar, please feel free to discuss it with myself or Dr Saleem Barbri (assistant-head of years 1&2)."

This is all very comforting, but it doesn't mean much. Every student with a few friends and half a brain can easily get their hands on a number of past papers. Model answers, are of course, another story entirely. However, explanation of why this is all so difficult is really hidden in the process by which it is learned in the first place.

At UQ, learning is based on the Problem Based Learning (PBL) system. It's in groups of ~10 and it's great fun. I reckon it works and apparently so do a bunch of studies. Whatever. The key to the whole PBL thing is 'Learning Objectives', which is basically a nice way of listing everything a student needs to learn in the two pre-clinical years. This year, the school's been nice enough to break the LOs into a week-by-week scenario (rather than the previous month-by-month option). LOs come from all the domains, including Anatomy & Physiology, Clinical Skills, Biochemistry, Ethics, Social Sciences. As Medicine is a broad course, this schema works well to define the greater aspects.

What that means, though, is the school shouldn't be able to crank out obscure, 'Pub Trivia' style questions exams. Which was exactly what happened at the mid-year. The question was part of a paper on Tuberculosis. Not a major disease we'd covered, but one of the four or five mentioned in one particular week of respiratory block. Still, thirty-five or so marks of 180 on a disease that, well, by my impression was under-'taught'. Nevertheless, it wasn't anything unfair, out of the ordinary or unexpected. But, on page three of the paper, this question;


So, that's the current situation; fluffy learning objectives, mysterious resources and modes of learning and ridiculous questions. Thus, the new format of writing our own questions would ascribe a bit more control, more sense and more testing the important stuff.

How the school has gone about this is designed to be empowering; give each PBL group a topic for a question, and get them to design one short-answer question (SAQ) and one multiple-choice question (MCQ) on the topic, each with answers. Regarding the SAQ, we're asked to give examples of a good answer and a poor answer, with justifications. Then, they'll show us all the questions we've written on the SOM portal for a month or so prior to the exam. Of these, a select number will be in the exam.

As far as being able to write a decent question, the SOM has provided us with stacks of examples, and each group has elected a question coordinator and it's quite all well organised. Some groups have even been given specific LOs that their question topic relates to. My PBL ain't so lucky; we've just got a topic: Encephalitis [Clinical skills].

Either way, I'm going to learn about encephalitis. It's just that I'll know maybe a wee bit more than someone from another PBL. Hey, they'll know more than me about epilepsy. At least, at the time they write their question. Just like in clinical practice, one person might know more than another about a particular thing. No big deal; we've all gotta answer the same question.

Anyway, what I'm getting to with all this is that essentially this is all good for our learning, and only a few idiots are going to do it wrong. After 18 months of Med School, you'd hope that most students have a good, firm grasp on what's important. That essential stuff like cardiovascular disease, neoplasia and the like; the stuff that occupies the majority of what we'll one day practice.

And to foil the wankers who go out of their way to write ridiculously hard questions, the answers are there for everyone. This will hopefully prevent aimless Zebra-hunting as an effective means of study (It's been pretty effective so far).

What's so bad about all this? Is it now folly to think that maybe, just maybe, Med students know what they need to know?

To all the nay-sayers out there, get some perspective. Medical students do have some ability to predict what they'll need to know, and crikey, we want to be tested on it. I'm looking forward to the end-of-year exam.

I'm going to be asked things I'll need to know; not pub trivia.

Joey: Over the line?! You-you’re-you’re so far past the line, that you-you can’t even see the line! The line is a dot to you!

I've been thinking about an article titled "Content of Weblogs Written by Health Professionals: More Bad than Good?", which I found via Medicine 2.0 (this week hosted by Monash Medical Student).

The article discusses good, bad and unethical blogs, as well as giving a few examples. It goes some way to commenting on what should and should not be included in Medical/Health blogs, and makes particular reference to disclaimers. It recommends the use of the following disclaimer;

This sparked three thoughts; firstly, as a Pharmacist, I'm officially a self-employed locum, with regular shifts. Technically, my boss is me. After reading a number of stories about this doctor or that nurse whom got the axe for saying something out of line on their blog, I was a wee bit disheartened. Being independent, I guess the worst thing I can do is really mess up my professional reputation, and have to go looking for work a couple of hundred km away. Hmmm.

Secondly, I consider one of the more unique points of this blog to be its dual nature; that is, student of one discipline whilst 'master' of another. I guess this can be a double edged sword; comments I make might be totally inappropriate for a physician to say, but on the other hand, an outspoken, somewhat cranky pharmacist can talk a lot of trash without copping any flak at all. Where does one draw the line between Practitioner and Student of similar fields?

Thirdly, the disclaimer makes no real statement about confidentiality. I reckon that's a big-ass mistake. Most of the good blogs I've read usually mention something along the lines that 'the patients mentioned within aren't real', or some such language. The best one though, took a few cases from throughout the week and mashed them all together, in order to emphatically illustrate their point. Kind of a 'worst case' scenario. I like that, and that's probably what I'll do.

-----

It's after 9.30pm, and I'm well into my 28th hour of work in two days. Tonight's 110km drive home will be at least an hour and a half. Longer if I stick to the speed limit. Buble is on the store stereo, "I wanna go hoooe-wooooome". He echoes my sentiments exactly; right down to the drawn out notes. Hmph.

Why do we do it to ourselves? It's crazy that I'm even considering bitching about this now, what with intern and residency yet to come. I'll be honest, usually the whole idea of trial by fire quite appeals to me. So does the notion that the more time you spend on the field, the more plays you see. But tonight, I'm tired and I'm not learning shit about shit. Plus, I just got threatened and busted a shoplifter inside the last hour.

Right then, home time. Pacific Highway, here I come...

Back in the thick of medical school, today's post is a conglomeration of events/thoughts from the last fortnight. I kinda figured that since I'd not posted about med school related stuff for a while, an omnibus-type post would go well.

Half a baby and Broken necks

In pathology recently, we've been focusing on neuro stuff. There were three pots that I found fascinating. When asked to describe the first of these pots, one of my more timid classmates replied,

"It's half a baby". Well, not quite, it was actually less than half a baby, as the foetus had ancephaly. This is when the foetus' brain fails to develop anything more than a brainstem. The cranial vault was totally absent, and it's pretty much a case of two eyes on top of the shoulders. The reason the specimen had been cut in half was to illustrate the internal malformations of, well, everything. The heart was at the level of the umbilicus and the intestines were twisted around the great arteries. The spinal column was a mess. Several of my classmates were pretty grossed out. Not surprisingly, there are differing levels of these defects, and they fall into the term"Neural Tube Defect". Whilst these abnormalities are not usually compatible with more than a few hours of life, Spina Bifida also falls into this category.

The second pot was also in this vein. The pot contained a brain from a foetus that had holoprosencephaly. This is where the brain doesn't split into left and right, and there is a general absence of midline structures, such as the nose and mouth. Instead, there is a single eye, so the still-born child is a cyclops.

The final pot seemed to hit closer to home for many students. It was the c-spine of a 19 year old male. The last thing he ever did was pack down a rugby scrum, before braking his neck in two places. Resulting in instant death.

Why did the third of these pots hit so hard? I think that whilst it's easier to write off the first two as freaks of nature or alien, the notion of some kid a few years younger than yourself killing himself playing sport is a bit more abrupt. If you make it to term with one or no cerebral hemispheres, life is going to be brief. I guess there's inherently a stronger insinuation of the potential for success and the future for the young chap who's snapped his own neck.

Well Woman?

Another interesting event this week was the Pap Smear and Breast Exam Tutorial. This experience is dreaded by many medical students, and most of our group was no different. Rather than pass any judgements or point out the problems with the program, I will briefly describe what all this entails. This is certainly an essential experience and the current programme slash learning model we use is extremely good.

The program hinges on women whom train and demonstrate the examination. Firstly, the group of students (ten only), are shown the components of the 'Well Woman' checkup by two demonstrators. One takes the role of doctor, the other patient. Together they work through a sexual history, a breast exam, a pap smear and a bimanual pelvic exam, with an audience of ten students.

Next, each student is allocated a demonstrator, and two students and two demonstrators go into a clinical room. There, the students are shown how to use the speculum, and important points of hygeine are reinforced. The first student/demonstrator pair work through the 'Well Woman' check as above, with the addition of a debrief for the patient/demonstrator about what has been found. The student is assessed by both their demonstrator and the other demonstrator in the room. The other student also observes. Feedback is given at all times, and the demonstrators are very aware of everyone's wellbeing, both physically and psychologically. After the first student has completed the 'Well Woman' check, they are given specific feedback. Then, the same order of operations for the second student occurs. There is general feedback and assessment given, and if the student's performance is unsatisfactory, they are referred for another session at a later date.

From my point of view, it was a shitload scarier than it should have been. The main reason being that there was very little chance to prepare for the whole thing (twelve days heads up), and what few resources there were are crap. Also, as too much emphasis is placed on the clinical side of things, it makes it much more challenging to establish a relaxed yet professional atmosphere in the clinic room. One thing that was done really well was the constant feedback from both demonstrators. They really want you to do well, and make sure you pass if you're competent.

Like I've said, the whole program hinges on these women. As a med student, when it's your turn to do this whole thing, make damn sure you thank them thoroughly because they do a great job.

When asked to describe the events of our Kokoda Challenge post hoc in two words, Hunter replied strongly;

"UP" and "DOWN"

I reckon he was totally on the money. For the first part of the race we were 'up', for sure, managing to run the first, say, 15kms, and staying in the top 15 teams. We were running the downhills and making great time. It was a beautiful day, not too hot. Our spirits were flying pretty high.

The terrain was not as we'd expected. The part of the course we'd already walked was completely different to the majority. Picture sheep tracks and 4wd tracks that had been gouged deep by rain only days prior, with rocks littered across varying from pebbles to half a brick. Keeping the ankles and knees majorly intact was a mission in itself, and hence smaller injuries were unavoidable.

The course has three major climbs, at the pace we were going, it was one before lunch, one after lunch and one after dinner. The first two were hard bloody slog, and I struggled up 'em at a pretty slow pace by comparison to the rest of the team. After the second hill, all four of us started to show the first signs of injury. No-one broke a leg or fell heavily or anything, just the repeated trauma of walking and running for 7 hours (40+km) on terrain we were unprepared for. We began to slow down quite a bit, but in the light of day, it wasn't so hard to have a stretch, shake it off and compensate by walking differently.

Night fell at around the 50km mark, and we were still making good time, remaining inside the top 40 teams despite having slowed markedly. Torches on and about an hour from dinner, we trudged on to the checkpoint and some warm spaghetti and a good rest.

The next part of the trek was by far the hardest of the event; 18km of night walking including the toughest peak on the course. Once we'd knocked that over, we'd be 30km from home; including 4km of very steep downhill, some road walking, and two short but brutal climbs.

Walking at night, our spirits fell. We were down. The night had closed in and wasn't about to bust into dawn anytime soon. Every single foot placement was precarious. Our aching bodies lurched this way and that to remain upright, moving and safe. There was no telling where the track went outside the 10m of torch-provided visibility and a glow stick some 80m in the distance. The night was young. The night was long.

The full severity of our injuries revealed themselves. One of us was heavily Trendelenberging, and I had reverted to using a stick. Ah, if only we'd not ridiculed those with walking poles all those hours earlier at the start line. All of us were quiet; fighting the battle within as much as the trail and the night without. At a snail's pace, we climbed to the road and checkpoint 9. We were about 5km prior to the major checkpoint, where the support crew, food, drink and possibly a seat were waiting for us. Trendelenberging became sitting, and after a ten minute rest, we were down to three.

We trudged on along footpaths and inched up the climb into the checkpoint. Thanks to my sticks and the nature of my injuries, I was much much faster up the hills than down them. I was at the head of a wounded team. We fell into the checkpoint, two hours behind schedule. It was after midnight; we had 30km to go. We were spent, wasted and down. The three of us had a long talk - about 15minutes - about what to do. Each of us fleetingly expressed a desire to continue, but several factors beat our spirits down. We were going to take about 11 more hours. Could we even last that much longer? I was to be cripplingly slow down the next hill, and the others likewise up them. Up and down.

It was game over.

Batman and Wonderwoman had been the support crew all day. By the time we'd made it back to camp and collected all the gear, stoves, food, clothing and other miscellany, they'd had a 24-hour day. The other guys had fallen asleep about 15 minutes after we withdrew, whilst Batman drove us back to camp. I stayed with her and Wonderwoman in a trance-like state, just to make sure that no-one fell asleep at the wheel. It was 4.30am. Everyone slept in their race gear.

At 9am, everyone was up. We cleaned and packed and made our way back to Brisbane. For sleep.

I'm writing this post four days later, and I've had a few talks with the other guys about what went wrong. There are plans for next year, and by gum there's unfinished business.
We will succeed.

It's Kokoda Challenge time!

It's been quite a while since I've done a true locum shift, but today is it. I'm filling in for a friend who's having a long weekend.

Locum is a shortening of Locum Tenens, which translates literally as 'place holder'.

A locum shift can be great fun; it's a good chance to meet some new people and patients and everyone's usually very helpful and makes you feel more than welcome. Also, you're not expected to know all the ins and outs, so you get cut some slack; just dispense without mistakes, counsel new medications and write in the controlled drug book. If you're so inclined, you might read the paper (I'm not a fan of this; I'll elaborate more later) or maybe have a wee browse on the internet. Good times, really.

The flipside, of course, is when it turns to shit. The shop assistant is late. The alarm code is wrong. The computers won't start. You've got methadone clients baying for your blood because you used too much orange cordial. Your shop assistants are morons. The EFTPOS craps out. The manager hasn't left you an emergency phone number. You do 300 'scripts. Before lunchtime.

Luckily, today has been the former; I love my job.

Whilst several of my colleagues have been at the annual AMSA conference in Melbourne, this week has been a good chance to not only indulge in some relaxation, but also to catch up with my family. Tonight, my grandfather regaled me with the following story that is at least fifty years old;

"I remember, when I had just finished university, I was at the local hospital for some operation or another, and my friend was a first year house officer .

He came to me, just to say G'day, but in passing mentioned that the chap in the bed next to mine was displaying some very odd symptoms and he couldn't work it out. The chap had been in for nearly a week and they were stumped.

The next day, I had the answer. At around 1am, there had been a rattling below our window, and the chap next to me had woken with a start. He'd clambered to the window and grabbed a piece of string and hauled up a bottle of whiskey. By the morning the whiskey was well drunk, as was the chap, his symptoms having returned."

This reminded me of an excellent anecdote from the preface of the first edition (1985) of the Oxford Handbook of Clinical Medicine (my current favourite)...

One should not miss alcohol withdrawal as a reason for post-operative confusion.

Peaceful, fresh Autumn.
Stop! Cease! Desist! Go away!
I am not alone.

In two weeks, I'll be either on or recently finished the Kokoda Challenge; all the planning is done, and the rest of the team and I have made our minimum donations (read: entrance fees). It's just a case of stretching out the legs regularly and taking it easy up 'til then. There's been some talk of carbo-loading. I'm inexperienced in these matters, but I guess it equates to doing a wee bit more than having a bowl of spaghetti the night before. Mmmmm. Spaghetti.


As you may have guessed, this post isn't really about Kokoda. It's about a guy in my class who has twice now weirded me out just a little bit too much.

The first 'incident' was last year during an antomy prac. It was the first prac in the year where we were able to do actual human dissection, and hey put this prac far enough into the year that people who are generally a bit soft and/or get queasy with the rawness of cadavers have had time to adjust before actually slicing someone up, and there's no actual compulsory cutting. Just give it to the baby-surgeons in the room.

I had joined another group because I had to work at the time my group was doing the prac, so I had been slotted into this one, and didn't really know anyone. The demonstrator was indicating correct technique on the cadaver's thigh, being the area of focus for the prac, and at this point it's all pretty normal stuff, ie. don't go to deep, take it in steps etcetera. I notice out of my eye, that one of my classmates, whom I've noticed before but never heard speak, is touching the cadaver's nipple. With his scalpel. He's flicking at it, trying to lift it up and see what's underneath. He does this for a full five minutes, before being asked a question by the demonstrator. He shrugs his shoulders indicating that not only does he not know the answer, he also doesn't want to speak. The prac finishes and I think 'Weirdo!'

Fast forward to Tuesday. The groups have of course been reshuffled, and whilst I don't share a group with Nipple Guy, we now are in the same Pathology Tute of about 45 people. He was teamed up with three mates of mine for an practice quiz that was to last about an hour. They'd not met him before, nor had I told them the story I've mentioned above. Anyhoo, as one does, one of my friends introduced herself. Here's how the conversation went:

Spidergirl: "Hi, there, I'm Spidergirl".... extends hand.
Nipple Guy: "Hi, I'm Nipple Guy". Shakes hand, awkwardly.
Spidergirl: "Cool, nice to meet ya. This is Flash Gordon and Wond..."
Nipple Guy (interrupting) "Look, I don't think introductions are necessary for just one tutorial."

Okay then. Eyebrows are raised, and the quiz begins. At the first station, Wonder Woman isn't certain about the answer to a question and she asks Nipple Guy if he know the answer. He repeats the information in a direct manner. Not in the "hmmm, I'm thinking" kind of way, more in the "It's this." kind of way. The answer stays the same, no stress. At the end of the station, a meagre ten minutes into the quiz, Nipple Guy quietly walks out.

I don't know what's going on with Nipple Guy, but it's pretty unfortunate that he doesn't appear to have anyone in the class he talks with regularly. I appreciate that it's not always easy to chat to new people in a class of 400+, but seriously, we're more than 18 months into the course. Safe to say, if he's such a hoplessly ineffective communicator now, he's gonna get torn limb from limb by the nurses and consultants in the clinical years.

Already a week into the second semester, I've got three things to say today;

Firstly, the case for this week was Drug Overdose. It focussed on a bunch of harm minimisation therapies and other behavioural, social and pharmacologic therapies. One such therapy mentioned was the methadone programme. I'm well familiar with methadone/subutex etc through work, and most of the intricacies of being on the programme. I was staggered to find out what they consider a success rate. Here was me thinking that a an average methadone patient might use heroin (or other IV opioids), say, two or three times a year. Turns out that a 'success story', would be someone who uses about once a fortnight. I've discussed this with some other pharmacists, and they reckon they're being had. By comparison, all the med students were thinking "Gee, that's not bad." After a bit of consideration, I realised that I shouldn't be as shocked as I initially was, after all, the first maxim of pharmacy is "Never trust a junkie."

Secondly, a big shout out to a guy called Dion Lane. I've never met him; I watched him on ESPN's lumberjacking series last week, and he was the only Kiwi in the comp. He blew the competition away and set a few world records. He's obviously a big man with a big heart. Purely by coincidence, he also appears in another blog I read regularly; Depth of Field. Random. Awesome.

Finally, I've been reminded by one of the Medical Misadventures about a curious sighting at Airlie Beach. The first thing I noticed was that there was a 2006 BMW 325 in the carpark of the backpackers. Possibly, it belonged to the owner, but no, it had Tasmanian plates. And it was filthy. And it had a Jesus fish across the back windscreen. And shirts and ties hanging in the window. Maybe a traveling salesman, I thought? Still, unlikely at the backpackers.

Eventually, I caught sight of the owner, and it all made sense. He was the epitome of sleazeball. Just the kind of guy you'd expect to be hanging around a place full mostly with 20-something buxom British backpacker birds. Greasy, curly hair forming an oily halo around the sun- and sun-bed ravaged face, adding years and wrinkles of a man pushing forty. The guy easily had a BMI of 30++, although the gold chains he was draped in would have pushed him neared the 40 mark. Here, I should describe the silhouette of a keg on legs, to actually see the guy's (minimal) clothing of (old school) bike pants/swimmers and chest hair was trauma enough. He strolled over to his car, opened up the passenger door and sunroof. He took out a $3 deck-chair and lit himself a cigarette. He smoked it whilst listening to a tastily ironic CD..... Greatest Hits by Dire Straits.

Overheard on Sunday;

Assistant "Would you like a generic or a less expensive brand?"

The patient replies, in all seriousness.....

"No, I'll have whatever costs the most, please."