Some people are just born with discipline.

At high school, one of my peers had, from the age of five, risen at 5am, pratcised his violin and done some mathematics study prior to riding off to school. Upon his return, he would complete his homework before his afternoon tea, then practice his violin, do some more mathematics and then listen to national radio for an hour or read a book until bed time. Not many Kiwis end up at MIT. But he did.

I'm always impressed by those athletes who stumble out of bed and into a pool, onto a bicycle or into their sneakers for a pre-dawn training session. Although I endured many early-morning sessions as a waterpolo player, there's a bit of a different set of obligations when it comes to team sport. Amateur solo athletes just seem to have an extra level of guts. They're doing it for no one but them. They want it.

I'm not sure what it is. For some people it's extreme fitness, for others it's a substitute to a morning coffee. And for others, it's knowledge or another goal that needs Hard Yakka to get there.

Throughout most Uni, my study habits have been atrocious. When it came to multiple hours of reading, or even taking more than a few pages of scribble as notes, my self discipline was frankly absent.

Similarly, I was, as my mum would say, a 'Call Out Kid'. At primary school, I wanted to talk. I didn't want to sit at my desk. I wanted to see what everyone else was doing. I wanted to tell them what I was doing. Talk talk talk talk talk. Yup, that was me. When it came to talking, well, I lacked discipline.

Not much of that changed over time; eventually I became, well, a touch more atuned to what I was saying and when I shouldn't say it. I still have a tendency to shoot my mouth off socially. Thankfully, one of the biggest things I've learned at med school is (some) ability to keep a lid on it.

This sort of self discipline developed in two phases; primarily, beginning to see the pharmacy-medicine coin from both sides saved me expounding my more outspoken pharmacy views. Especially to patients. Prior to seeing patients more regularly in a med student setting, I'd often give pharm patients great detail about what to expect for their entire treatment plan. Now, in a pharmacy setting, I'm much more focused on that aspect of care, and making sure the patient understands that.

Additionally, in the first semester of med, I was expected to be a guru in some aspects. I did, after all, work as a pharmacist, so I must know a thing or two about drugs and symptoms and the like. Right? Unfortunately, my basic physiology was, well, crappy. It wasn't up to Med1 standard. It doesn't pay to 'show you know' if really you don't. Step one; study more effectively. Step two; talk later in the piece.

So, in addition to that pure fear and respect that fresh Clinical students feel on Consultant Rounds, perhaps a level of self discipline might have also helped me keep my trap shut. It certainly helped me remember how to study again.

I've been blogging for exactly a year.

When I started last March, I didn't know what I was going to do but that I wanted to do something. Medicine can be all encompassing, challenging and rigid. At 3am when you need to know this list or that list, or on a Sunday when you're earning to learn, your creative drive seems to evaporate.

That's why I started.

I keep going, too, because with blogging, at any computer with an internet connection, from Uni to Rural Poland, anytime from office hours to all hours, an outlet awaits. And people seem to read my musings, and they sometimes tell me that my posts are thought provoking or challenging. I hope that I offer some interesting view of Aussie Medical School, Pharmacy practice and other ramblings I fire off into the ether. I reckon that there aren't many aspects of society that are as 'levelling' as blogging; the chance to interact with gun clinicians and such a diverse group of patients, students and allied health is unparalleled in terms of the respect afforded to one's blog colleagues.

And so, I blog.

Happy Bloggiversary to me!

It's exam week. Actually, this year every ninth week is exam weeks. But still.

Apparently Internal Medicine is the hardest rotation. You have to learn everything that's not surgery, pediatrics, O&G, mental health, General Practice, anaesthetics, Rural Medicine. So, pretty much everything.

My colleagues and I have been pulling roughly 10 hours days at the hospital for the last seven or so weeks, and for me, it's been great. Involved, intense, insightful, the works. The 'long' hours were starting to get to me a few weeks ago, then two things happened.

Firstly, I read through the latest AIHW report "Health and community services labour force 2006" (released March 9, 2009) about the hours that health professionals pull. Of the 57,019 doctors in Australia in 2006, the average working week was 45 hours. The lowest average working weeks were scored by the pathologists(40), radiologists(41) and rheumatologists(41). Worth mentioning are GPs(43), Residents(48) and Physicians(46). The most hours all went to surgical specialties (average of 54), most notably paediatric surgeons, who worked on average 61 hours a week. Which, I think, all seems to make sense. There's not really part of me thinking "Wow, that's waaaay to much hard yakka", or finding it wholly unreasonable. Demanding job, long hours. Makes sense to me.

Secondly, I arrived early one morning, about five past seven, and find that the Med Student common room has been overrun by half a dozen registrars. They're handing around printouts to each other and going through old exams to prepare for their Part Ones. I was impressed. They'd been there since about 5.30am. Studying. Now they were packing up to start their twelve-hour shifts. As doctors. Where they were actually responsible for patients and decision-making and teaching juniors and medical students. I was awed.

There's loads of talk around about the tough hours that interns, junior doctors and docs work, but they don't really approach the issue of 'study time'. The next time some pissant 20-something medical student complains about how hard it all is, how study wrecks their social life, how they can't play sport anymore, just think about the registrars. Their only study time comes between twelve hour shifts.

Now that's Hard Yakka.

Possibly the most relaxing afternoon's solo study I've ever had.

One of my most nervous days in Pharmacy was the first day I worked as a registered pharmacist. I still remember the first 'script I handed out.

But what was different? I'd worked my 2000 hours, I knew my stuff and I could run the day-to-day workings of a pharmacy without having to think about it all too hard. I could dispense safely, I'd passed my reg exams. Why was I nervous?

That first 'script was Augmentin Duo Forte - the common cure-all antibiotic - which further pushed the point home.

"This one's twice a day, ideally with food, but it doesn't matter. Have you had it before? No? Okay, are you allergic to anything? Penicillin?" and on I went. I counselled until the lady wanted to leave. But I was safe.

I was responsible. The line.

That morning on the way to work, I'd thought about the doom and gloom legal lectures from Pharm school, about pharmacists, either incompetent, hapless or nonchalant who'd dispensed without thinking, or counselling or practicing pharmacy. How they'd hurt patients. How they'd been sued. Or deregistered.

Responsibility hit me. It wasn't a sudden thing; my preceptors had ensured that over the 11 months of pre-reg that I'd been accountable for my actions, slowly but surely, and that I was safe and aware.

That first day (or week, in all honesty), was like getting my P-licence for driving. I was aware of the ramifications of my actions (or inactions). It reminded me of the whole learning to drive process;

1. Aged five. You don't know that you don't know. Cars drive around the streets. Mummy or Daddy sit behnd the wheel and do stuff and you go places.

2. Aged fifteen. You know that you don't know. The engine's on, why aren't we going? What does that pedal do? What's a clutch? This is hard.

3. Aged sixteen. You know that you know. I can drive. Check my mirror, into first and takeoff. Indicate at the roundabout. A policecar! Brake on the straight before it's too late.

4. Aged twenty-five. You don't know that you know. Off to work. What's on the radio? This station sucks. Which CD? I hope I can find a park. Yurgh, this traffic!

In the same way that drivers are not immune from accidents, Pharmacists are not immune from errors. But, when conditions get tough, the good driver lets their training kick in and reverts to basic principles. Same goes for pharmacy. Every time.

This line of thinking was triggered by a conversation I had today with one of the interns at the hospital. She mentioned that she found it hard to relax and switch off during the prolific downtime afforded during weekends 'on call'. At first I thought that this was a bit silly. I mean, if there's no work to do and everyone's healthy, you can relax, right?

At the pharmacy, if there's actually no work to do then I relax. I'm not a 'newspaper pharmacist*', but if there's not work to be finished then, well, it's okay to chill out; the patients will come to you. Meantime, grab a glass of water. Have a bathroom break for the first time in ten hours. If something happens, no worries, you'll handle it. Worst case scenario you have to call someone else. You've seen plenty. Your basics are good.

Then I remembered that feeling of responsibility. It doesn't surprise me in the slightest that three months into the term, an intern still buzzes through the whole shift on call.


*Newspaper Pharmacists will get their own wee post in the coming weeks.

Most people have had the odd sleepless night. The feeling of tiredness washing across the senses, without sleep taking control. The grittiness that comes with opening the eyes at half three and not being able to return to the world of slumber. Or the rolling, kicking, turning just to get comfortable. When a night is too hot, too cold, too light, too dark, too loud or too quiet. Sweaty feet or cold shoulders. Mind racing about the frustrations of today or the anticipations of tomorrow. And, eventually, that feeling of exhaustion as you plead with the night to allow a few hours, or moments of all encompassing, resting sleep.

Unsurprisingly, not a shift goes by when someone asks me about sleeping tablets. "I just haven't been sleeping well", they say, "and I, well, I just want something to knock me out."

Of course, there's no chance of getting benzos or other hard sleeping tablets; the limit in pharmacy is a few sedating antihistamines. And, yeah, quite a few people like to chow them down. If it's essential, I usually go for the smallest pack size of an agent that'll work.

I don't like recommending 'sleepers', because for most patients it's overkill. The key, I reckon, is a good sleep routine. Plus, making any tablet part of your sleep habit unnecessarily is likely to be, well, habit forming, right?

If you're a glasses-wearer, it's pretty simple; you take off your glasses and you can't see. You're used to not seeing a) when you're sleeping or b) at night. So your brain twigs that it's sleep time and off you go to the land of nod.

Clearly, the not seeing equals sleeping is a tad idealistic. I've heard of several effective techniques, on top of the good old routine that is (roughly); close curtains, pyjamas on, wash face, brush teeth, snuggle down, fall asleep.

An oldie (+/- goodie) is a warm glass of milk. Not so hot if you're lactose intolerant though. I'm not massive on late night milk, myself. I much prefer the quiet, relaxing music, with a bit of a beat to it. A few examples of bad would be; Nirvana, AC/DC and The Rolling Stones. A few ideal examples would include Moby, Coldplay, Enya and The Postal Service.

Obviously you're not trying to blast your ears off, just loud enough that there's something to hum too if you need and a enough base to sense. The same as for wee puppies when you use an alarm clock to emulate the mother's heart beat. That kind of thing.

But, most importantly, if you're not getting good, regular sleep then see your doctor about it. It compromises your ability to work or learn and it's generally bad for your health. And because feeling exhausted, sleepy and frazzled, as a part of a regular day, well, it sucks. Time for bed.

Anyhoo, I've had in my mind for quite a while which specialties are definite possibilities, as well as those which are definite no-go zones. Since I've only done internal med, I consider many of my views to still be a bit on the theoretical side, but hey, that's how it goes.

At the moment, Radiology and Pathology are well out. I get that they're good fun for interest's sake but not every. single. day. Plastic surgery is made noble by a few, but there's a bit too much... plastic... around that neck of the woods. I'm not a big fan of Gastroenterology either (insert poo joke here).

Strongly within the realms of possibility are; Cardio, Respiratory, Psychiatry, Emergency Medicine and General Surgery.

My current 'Hot List' is (in alphabetical order only);

• General Medicine (It's better than knowing a little about a lot. It's knowing a lot about a lot, right?)
• General Practice (The appeal of womb to tomb, maybe not so much at the dawn of my career, but that work/life balance I'll want. Eventually.)
• Oncology (It's intense, caring, evolving, fascinating and isn't what I'd call 'for fun' medicine.)
• Obstetrics (& Gynaecology) (Yeah, blokes can still do this; it's got good amounts of public health, medicine and surgery. Rockin'.)
• Paediatric Medicine (Make a big difference to a wee human's future, yeah?)

Undoubtedly, the next few months, years and so on will see this list change, shrink and generally morph. Oncology wasn't even a consideration at the start of Med School, but I find it making the above top five list quite comfortably.

This morning's quiz, though, made a suggestion completely out of the box; Aerospace Medicine.

You can read the rest of her acceptance speech; it's a veritable feast of Aussie Medical Blogging. You should totally read it. Like, the second you've finished reading this post.

Thanks to Dr Cris of Scalpel's Edge and AppleQuack for organising the awards, as well as SitePoint for providing such a red-hot prize. Finally, a big Huzzah! to those of you who voted for Degranulated :) Thanks team!

Now go here...

As promised, this is round Three of the Pimpin' Quiz. The time limit is now no time limit, so it's first in, best dressed, people. Of course, the prize is still a personalised "Pimpin' Quiz Winner" banner. En garde!

Several years ago, I witnessed a patient with pseudoseizures. She was investigated for all number of neurologic disorders, and some of her seizures were real; stress induced. It appears retrospectively that the others were mostly an attention grab. It scared many of the people who knew her.

More recently, a nurse friend of mine related to me a few stories about patients with pseudoseizures, in what would best be described as a light-hearted tone. The lengths some patients would go to defend their 'seizures' were just plain silly.

Picture a patient accused of faking a tonic-clonic seizure stopping and saying "I am so having a seizure!" Or when one nurse remarks to the other, within the patient's earshot, "You shouldn't leave those fluoro lights on, they can set off seizures." Needless to say, a 'seizure' ensued within seconds.

Let me be clear; Pseudoseizures are not funny. Evidently, there are some potentially humorous stories about pseudoseizures, but, in person, to witness or to have, they are not funny. More appropriate adjectives might include worrisome, concerning, irritating and dangerous.

You see, the population most at risk of pseudoseizures is, in fact, patients whom suffer (genuine) seizures. Chances are, if you present with refractory, extremely convincing, pseudoseizures, you'll be treated via the same protocols as for status epilepticus. Not fun.

There's a long list of things that cause seizures. It's a pretty serious list, too, being that seizures are oftentimes life threatening. Uncontrolled epilepsy, brain tumours, drug overdoses and the like are, well, they're a formidable lot; the cause of any seizure certainly warrants a full investigation.

Thankfully, most textbooks point out the common features of pseudoseizures that are not consistent with seizures. These include pelvic thrusting, a lack of head thrashing, ability to listen to and abide by instructions, eyes tracking across the room and a lack of post-ictal confusion. It's also worthwhile noting that urinary incontinence has been known to occur in what would be best described as severe pseudoseizures.

And, deep down, you might understand some of the logic; these patients have a history of seizures and crikey, they know what kind of response it gets. Plus, it's far less risky than attempting to top yourself, and much more socially acceptable than throwing a temper-tantrum. So, why not fake the odd one, just now and then. Going out on a limb, I'd say that there's certainly another common denominator with seizures and pseudoseizures; Stress.

Psychological stress does messed up things to people most of the time, but, hang, throw a neurological disorder into the mix and it's all on.

By this stage of the post, the chances are that readers who are familiar with seizures are a wee bit miffed. I'm sorry. I'm not blanket accusing seizure sufferers of attention-seeking. Not in the slightest. As I've mentioned earlier, seizures are a big deal and should be appropriately treated and, after the event should not be negatively socially stigmatised.

What I am trying to illustrate is that seizures, pseudo- or otherwise are freaking scary entities, not least for the person they're happening to. But a pseudoseizure, if a patient's having one consciously and intentionally, is like a really nasty joke to which only they'll ever get the punchline. Kind of like the opposite to a Dissociative Fugue...