Last time, I wrote about moving from just being able to make simple decisions to more complex situations, and how we become more comfortable with making said decisions with experience and confidence.

With experience and time, one operates at what is essentially a higher level of thinking. The majority of questions are essentially 'no-brainers'. You're flying on autopilot, you do the safety checks and keep zooming along. Being aware that you're on autopilot is essential, because then your sensors are on; if a warning pops up; you'll notice it.

When you're unaware is when danger strikes. My pharmacist colleagues agree that the most dangerous phrase in pharmacy is "That's fine." It's so easy to say that you barely notice any of the surrounding warning signs. A good example of this would be a shop assistant asking; "This bloke's on Coversyl(R). Can he take Nurofen Plus(R) ?" You glance up, he looks about fifty. It'd be very easy to say 'That's fine', and that may well be right. But, has the pharmacist considered: a) What strength is the Coversyl(R)? It's seldom prescribed alone in the higher doses. b) Diabetes? c) Diuretics? d) Renal failure(!), e) What's the Nurofen Plus(R) for? and so on. It's important to think about, if it's a fast, effective consideration of the information, then so be it. Just because you know the odds, doesn't mean you need less information.

Sometimes a situation arises that requires faster or more complex decisions, or both. These are stressful situations, where if your basic game isn't sound, you're most likely to wobble or screw up. Or get flustered. When this happens, it's essential to keep cool and revert back to first principles, because they don't change. One of the first pharmacists I worked with said to me;

Capt. every time you look at a 'script, read out the name, doctor, drug, strength, quantity and directions out loud. It can be in a tiny voice in your head - just make sure you say it. Don't stare at it. Say it. Say it once for the original, once for the label, once for the box and once for the repeat. If you do this every time, you will never make a dispensing error. No matter what else is going on in your life, all you have to do is say it out loud.

This is possibly the best advice I received as a pre-reg. Obviously, there's not a lot of reasoning happening when you check a script. Clearly, though, it's essential to be able to perform the core tasks. In Medicine, clinical reasoning is one of these tasks. Your skill in weighing the relevance and mechanisms behind this information is key. Sometimes there will be huge amounts of information, much of it conflicting. What to do first? What about the Sodium channels? What's with the tachycardia? (Flustered, much?) How to prioritise?

With no formal clinical experience and not much direction, it's an ongoing challenge to sort the sweet chocolaty goodness of information from the other brown stuff. And it seems sometimes that one can morph into the other without a moment's notice. Again, Murtagh's General Practice has come to the rescue; the first page of the emergency care section states;

1. The practitioner must be aware of life-threatening situations.

Gold. After seeing relatively sparse numbers of patients to this point in medicine, all of which had multiple, complex comorbidities and were managed by various specialist teams, this single sentence really crystallised what's most important; to simplify. Work out what the primary complaint is, and then everything else. On the myriad of information to be processed, I was offered this salient ray of light by one of my Docs;

In medicine, you only have to think about one decision; the next one.

And that's what I will remember; Remain unflustered and simplify.

Some people are always in a rush. The smallest thing becomes a huge problem. Everything is busy, they need to be somewhere, like five minutes ago. They can't sit still for more than a few minutes; there's always a question or directive on the tip of their tongue. Their manner spreads panic and uncomfortableness. And, when they leave, things are tense and agitated. The situation disintegrates. They are, in short, forever rattled.

Some people are never perturbed. They're so under control, they're relaxed in really stressful situations. Things appear to be a breeze, and the closest they get to really stressing about something involves the brief interjection 'Hmm' at the start of a sentence. The answer comes in good time, and it is well considered and comforting, it assesses the present, appreciates the past and plans for the future. They are, in short, unflustered.

When I first began team sports everthing felt like a rush (except fielding at cricket, of course). I'm a pretty keen sportsman, and, well, I'd put myself at above average coordination. Still, until I hit the age of nineteen I never felt like I had time on the ball. I was competent at drills and training, and now and then I'd have moments of serendipity. Generally, though, I'd marvel at my colleagues and 'the time' they had over the hockey ball, or at picking the gap on the rugby field. I could still do it, but well, things felt rushed. Most average sports-people have the set of issues; taking your eye off the ball, fumbling under pressure and the like. By second year Uni, my sports skillset had changed markedly. On the hockey field, many of the blokes I played against were a bit older (they didn't chase young 'uns), and I didn't feel pressured in the way I had at school. I matured as a player and had more time on the ball. I still ran around as I always had, but thanks to some sporting self-confidence, I could think about where the pass was going or 'hold up the ball'; I began to enjoy my hockey much more.

When I started as a pre-reg pharmacist, I went red a lot. Not at home mind, and not when I was doing mundane work like stocktaking. Only when I was doing 'Pharmacist' jobs. If there was a line-up of 'scripts, or making a cream or even selling paracetamol, I would turn crimson and get my mist on. Comparatively, I almost never went red when I was talking on the phone to patients. I rarely felt 'flustered' as such, but the apparent physiological response indicates otherwise; still, I didn't go about my business in a mad rush. As I approached Registration, I realised the flushing had gone. I rarely needed to look up doses and I could pick OTC drug-drug conflicts at thirty metres. I knew the answers to questions about Warfarin and other relatively complex interactions, and was able to rationalise the steps to each solution. Explaining concepts like blood pressure and allergies to Joe (? the Plummer) became part of my everyday thinking and communication style.

This post is the first of two in a series on Clinical Decision making. Predictably, making clinical decisions is one of the most challenging aspects of early practise in both medicine and pharmacy. Being able to weigh up the information for relevance and importance, then act on it. With time and experience one develops knowledge and understanding about the decisions they make. One must still remember the facts and reasoning behind their advice, and apparently, the more decisions you make the less red you turn!

This morning there were about a twenty Anti-abortion protesters outside my medical school. Now, I'm used to seeing protesters on my way to PBL. There's usually one or two camped outside the local clinic, a few blocks away, holding their signs and getting cars to honk. Not many cars honk. But protesters outside Uni was something entirely different; they were coordinated, and chanting and really waving those signs with enthusiasm. Ironically, we were learning about STIs, hydatiform moles and the like. These protesters annoyed me, not just because their loud chanting disturbed my learning, but also because they're pushing their views onto other people.

Of the women I know who've undergone a ToP, none of them did it lightly. They are aware of their choices, and the options available aren't ideal. There is much guilt. They don't talk about it freely. Each week when I drive past the old, stagnant men, shoving their placards at the women who've made their choice, I get cranky. These blokes have no idea about the woman's circumstances. They're simply hurling abuse and idealistic viewpoints at a vulnerable young women. It's always good to kick someone when they're down.

What winds me up is that is that the people harranguing the patients are invariably men. They haven't been in this situation; they don't live with the consequences of their point and shoot activities. If they have endured some semblance of the emotional turmoil involved, they'd sure as hell have some sympathy.

I appreciate that abortion is not an operation that should be performed 'on demand'. It's not a form of contraception, it's not the 'morning after' pill. ToP is morally serious. The moral debate centres on the rights (if any) of a foetus vs the rights of the woman.

There is currently public debate about the issue in Victoria. Pending a vote in the Upper House, abortion will be removed from the Crimes Act. Currently, as with most Australian states, in Victoria "unlawful" abortion is illegal. However, "The “Menhennitt ruling” (as mentioned by de Crespingy and Salvulescu,) stipulates that an abortion is not “unlawful” if a doctor believes that the abortion is necessary to preserve the woman’s life or her physical or mental health. The upper limit of gestation is undefined."

Some doctors and academics have vociferously opposed the changes; One doctor has placed the a sign at the door of her surgery announcing that she will not be complying with the new laws. How does the new law effect doctors? Two main points; firstly, that abortions may be legally procured before 24 weeks. The opposing doctors argue that the cut-off should be twenty weeks. I don't consider myself informed enough to argue one way or t'other on this point.

Secondly, the opponents argue that the bill does not adequately deal with doctors whom object to abortion on moral grounds. In medical school, we are taught that the patient has a right to be made aware of all their options, and if a doctor is unwilling to refer a patient for a ToP, they should refer the patient to a doctor who is willing to explain all possible options. In this way, the patient's autonomy can be fully exercised. The opponents of this Bill appear to not currently do this. So, do they believe paternalism or patient autonomy, or even womens' rights? Hmph. Isn't it good to see how times have changed.

As far as those protester blokes at the clinic go, I enjoy imagining someone lobbing eggs their way in a drive-by. I doubt they'd get the irony.

---

Some other resources:

Abortion: time to clarify Australia's confusing laws, Lachlan J de Crespigny and Julian Savulescu, MJA 2004; 181 (4): 201-203 http://www.mja.com.au/public/issues/181_04_160804/dec10242_fm.html

The house up the road from mine just got hit by lightning. The storm that's been threatening all day came across an hour ago. I knew it was coming, not just because of the weather and wind warnings all over the TV and radio, but also because my sinuses have blocked up and I've been clenching my jaw all day in an effort to clear out my ears. Fruitlessly.

The pounding headache that's ensued has given me sufficient excuse to procrastinate, culminating in sitting outside for the last hour watching the heavenly fireworks that were previously South-west of here, and are now overhead. The international match between the Socceroos and Qatar has even been delayed.

It's the first major storm for the Queensland season; it's hosing down and the sky's like a strobe flare. Despite being well after dark, the orange electric glow hangs across the skyline and that crackly feel dances on the skin.

The electricity in the air reminded me of a similar storm a few years ago; in Pre-reg. Mr Wills had been an off- and on- patient for nearly a decade. He'd travel past about four other pharmacies and pop in for medications for himself and his housebound wife. He wasn't a big talker, Mr Wills.

On this particular day in October, the storms had been forecast to hit in the afternoon. It was midday and, much like today, the air crackled and fizzed. Mr Wills waited patiently for his 'scripts and the sky opened.

When the meds were ready, I handed them to Mr Wills in a plastic bag, and he mosied through the now pelting rain to the bus-stop about fifteen meters from the pharmacy door. A few minutes later, Mr Wills stumbled back inside. He'd missed his bus by a full forty seconds and the next one was due in three-quarters of an hour.

It was a quiet day at work; for some reason, the hail, drenching rain and lightning were keeping people away from the pharmacy, doctor and shopping in general. I conferred with the boss and ducked out to fetch the delivery car.

All the way to his house, Mr Wills and I had a good chat about his family and the area and all that sort of thing. It was a very different side to a bloke who was usually so quiet. He warmly thanked me as I dropped him off. I low-geared the deliver car out the muddy driveway, and headed back to the dry, quiet, pharmacy.

In the meantime, tonight's storm has begun to subside. The lightning's fizzled out and the rain has eased. Australia won the football, 4-0.

Academic institutions are well known for their amazingly frivolous and ineffectual expenditure. Mine is, of course, no different. Here in Queensland, we are party to twin, equally brilliant wastes of money, the Turkey Patrol and the UQSoM Balloting process.

UQ has a resident population of Bush Turkeys. The Turkeys roam the grounds, scratching up their piles. To aid these wee bird, we have Turkey Patrollers. They're groundskeepers. The Uni kindly provides them with a ride-on lawnmower with a trailer. In the trailer is a shovel, a rake and a leaf-blower.

The Patrollers' job is to clean up the piles of bark and leaves that the turkeys scratch into mounds and piles across the campus. On the roads, footpaths and walkways, these mounds ebb and flow. A constant battle between the anarchistic Turkeys and the orderly Turkey Patrollers. Funny to watch; preposterous to pay for. Especially the leaf-blowers.

A few weeks ago, I posted about the impending Clinical Rotation selection process. This week, a nightmare has, for some, come to fruition. Gloomy fruition. People are wandering around PBL in a daze; to stressed to study. But why? Whyyyyyyyy?

About a month ago the SoM proposed an electronic method whereby my colleagues and I could harmoniously select our Clinical School preferences for next year. Distance wise, there's about 800km between the two furthest Clinical Schools (CS), so it's not a small division. Each CS had a chance to promote itself, and then for a while, nothing happened. We were supposed to log on one day and have it all be wonderfully peaceful and collaborative.

What actually happened was *quite* different. Instead, the SoM reverted to a paper format, and asked us for three preferences. After two chances to change our preferences and a butt-load of wrong information, we were told the final time to change by. For this last change, only changes into the Rural School would be accepted. Next, it was announced via email that all students should have their mobile phones handy for the next few hours, as it would be necessary to allocate some students to rural locations. And, with all the transparency of obsidian, a ballot occurred. The entire class was tense, nervous and frankly, either treading on egg-shells or trawling facebook and the UQMS forums for information. Woe betide he whose phone rings.

And with that, it all began. 370+ Med Students scratching around for information, feeling like turkeys.

At about 9.20pm, I was out at dinner with Batman and some others, and the word came from Lickety-Split (c'mon people, haven't you seen My Little Pony?), that she had been called by the SoM. It went like this...

SoM1: "Hi, this is student rep. from the SoM. I'm really sorry to inform you that your preferences have been filled and you've been balloted. You choices are; Tinytowns one, two and three."

LS: "What? I can't go rural... that's not fair. Ow."

SoM2: "Hi, this is staff administrator person, your choices are; Tinytowns one, two and three."

LS: "Can I find out where my friends are going, or who else is going somewhere?"

SoM2: "Absolutely not. We cannot provide that information."

LS: "Well, I have The Laser sitting right next to me, can you tell me where he's going?"

SoM2: "No. That would breach privacy. Have you made a choice?"

LS: "I have to decide now?"

SoM2: "You've got five minutes to decide before I call you back." *click*

About 90 seconds later, Lickety-Split's phone rings again.

SoM2: "Okay, so have you made a decision?"

LS: "I'll take tinytown two, I guess... but... what happens now?"

SoM2: "More information will be provided in the next two days. Goodbye." *click*

Ridiculous. I guess, if you're unfamiliar with this kind of situation, it's pretty hard see what all the drama is about. For most people, their first preference is likely to come through...

In the case of some students, there's a very real possibility of people with spouses, families and mortgages getting sent somewhere they didn't bargain for. And people with three+ years of a relationship, apparently counts for nothing. Ditto organising any major Med.School-related events. Goneburger.

Also, in Australia, if you've flown the nest, you need to earn to learn, unless you're on loads of scholarship money. Being put in the situation where you've gotta relocate or drive for an extra 3hrs a day can reduce someone's ability to go to work., and relocation provides substantially more challenges. The SoM geneously pays the rent, but you've still got to have the cash to drive, clothe and feed yourself. Sensible, right?

No one has any idea what's going on. Everyone is stressed about missing out on their choices and the process feeling well out of control. This is most unwelcome for us med-school-types who like to be in the driver's seat. Raw emotion runs riot!

Ironically, the people getting shafted are those who expressed the biggest desire to remain metropolitan. Lucky sausages like me, who put Coast, Rural, Rural didn't get a call to say, "Sorry, it looks like someone needs to be closer to the city than you... Are you okay with your second preference instead?" Far too diplomatic for the SoM's liking.

I was intending on finishing this post off by detailing my plans, complete with a celebratory smiley face, but I can't, really. There's two reasons for this; firstly, the announcement has been delayed until next Monday, and secondly, despite my first preference being reportedly under-subscribed, I still have this sinking feeling that I'll get the shaft to Woop Woop (and not in the method as for 4.). As my previous post will contest, I'm actually unopposed to going rural - finding a job being the primary challenge. It's more that the School would be saying one thing and doing another. Right now, I'm sitting as pretty as possible; I really feel for my colleagues who are getting swept into a sea-change by a king tide.

Until next time, then, when my plans may indeed be revealed! Meantime, I'm going back to watch those Turkeys.

Something that strikes fear into any medical practitioner are Errors and Mistakes. In their worst form, Mistakes can kill people. Mistakes can end your career. In their gentlest form, a Mistake saps your confidence and brings self-doubt raining down on your every clinical decision.

On the Medical/Doctoring front, I'm yet to make a mistake. This is because I've not yet had one iota of responsibility in this setting. Comparatively, in Pharmacy I have made mistakes. From a purely mathematical point of view, it would be nigh on impossible that I haven't. Today, I'm going to discuss a some of my 'errors', and how they fit into the context of both medical and pharmacy practice.

My first error of the dispensing kind was aged 12. I was organising a basketball team, and I'd typed out a phone list and distributed copies to all the kids in the team, so we could find out who was playing each week. Unfortunately, despite being captain, I was never contacted. I had unwittingly swopped the last two digits of my phone number on every sheet. I guess I didn't read my own number, if I read it at all!

More recently, I was due to attend a mate's Birthday Dinner after work. I was planning on swinging in for a full ten minutes before crashing out at home, as I was working a marathone weekend. I'd spoken to the guy a few days earlier, and he'd sent me a text with the restaurant's details; King of Kings. I parked in the Valley, and strolled to Chinatown. I looked inside and couldn't see any of my friends. I phoned him to discover that he and the crew were at King of Kings in the City - about 15 minutes away. I went home to bed, quietly pretty cranky at myself.

Basic 2: Communication between pharmacists, pharmacy staff, doctors and patients is essential in reducing mistakes.

Mrs Watson answered the phone. Thank goodness she was at home. I asked if she had the box with her, and she says, "Yes, yes, it's right here." I checked which strength it was; the wrong one. "Okay, don't take any." I asked if she was going out in the afternoon; she wasn't. I explain that I need to get the medication somehow...

A few years ago, I lived a pretty slovenly flat, in which the cooking was quite sporadic. One night, my flatmate cooked a delicious Thai Green curry. Yum! After the meal, the dishes accumulated as they always do; about two weeks later someone decides to do the dishes. Lastly, the dishwasher gets to my rice cooker and reveals a pungent green mess of mould, rice and some sort of orange fetid water. There was gagging. It was stuffed. I had seen the rice cooker there for all that time. I'd even thought, "I should clean it up." But, hey, it wasn't my turn. Someone else would do it.

The three non-pharmacy incidents I've mentioned merely annoyed me. I felt dumb for making a silly mistake, but I knew that it wasn't anything more. I may have even looked stupid. Whatever. But a mistake that potentially causes physical harm and/or loss of life, that's a different story. Whilst the majority of pharmacy mistakes aren't clinically significant, when your job is to make sure errors don't happen at all, it results in a bit more self-reflection.

Last weekend was the Australian Rules Grand Final; it's one of those odd sports that one country is obsessed with and no-one else plays. Like American Football or Jai-Alai. This year, the underdog Hawks upset the incumbent Cats in a gritty match. My team, the Sydney Swans were bundled out of the finals with two rounds to go, finishing a credible fifth.

In AFL, there's a 'five-minutes remaining' siren for each quarter.

Since final exams are fast approaching, this is my five week siren. These are what the SOM calls 'Hurdle exams', and they're the summation of all the pre-clinical years. They will be the usual pair of three-hour writtens and a marathon OSCE (called MSAT in this neck of the woods).

My guess is that blogging may be a tad lighter for the next month and a little bit... but don't worry, I guarantee at least one story a week!