Not many things in this world are absolute.

This phrase tends to resonate increasingly as I progress further through medical training; I find myself more and more using terms such as likely, unlikely, often, rarely, common and usual.

A professor, in the first few weeks of Med, lecturing our class said "Medicine is about the odds, the chances. If you know the odds, if you know what's likely, what's common, most of the time, you'll be right."

The Prof went on to discuss Bayes' Theorem, Pre- and Post- test likelihood and associated matter. In retrospect, that lecture, given to half a class of exhausted MBBSI students, at 3pm on a Friday all quite overwhelmed with knowledge, was a washout, only because, unlike the Hotel California, we were not "programmed to receive."

Deeper into the Rabbit Hole, it becomes apparent every day the importance of understanding Bayesian theory at a deeper level is essential to Good Clinical Practice, as is an acknowledgment that nothing is absolute. Indeed, we are taught the value of data analysis, and develop the skills to establish what is likely, or unlikely.

Today I attended a lecture about 'Troponinitis', that is, the differential diagnoses for elevated TnI. After the lecture, Lt TriN offered a 'three line' summary, thus;

An important lesson here is that Point 3 can only be satisfied with a knowledge the causes of elevated Troponin. For a good list, check out the paper by Korff et al, mentioned below.

As I've said, few things are absolute. It's a brave physician who'll respond to a clinical question with a jovial Absolutely! Sure, some diagnoses reveal themselves incontrovertibly, but not all. For the rest, the physician might diagnose an disease, or recommend a specific treatment, but remember, they're playing the odds. They have a list in their head (or on paper) of Differential Diagnoses, and one or two is most likely. Perhaps, in the words of Bergson;

An absolute can only be given in an intuition, while all the rest has to do with analysis.

Reference: Korff S, Katus H A, and Giannitsis E; Differential diagnosis of elevated troponins; Heart 92: 987-993.

In the summer of 1993/94, I slowly became aware that the world around me was turning fuzzy. The poplar trees at the edge of the paddock blurred in a mess of brown and green; I couldn't see the raspberries on the vine, let alone their sharp protectors. My cricket suffered, and I was out bowled more than I was out caught. An eye-opening moment came when I couldn't see a ten foot sprinkler from about twelve meters away. But I wasn't certain.

Then school started, with all the excitement of the final years of Primary School. I approached the new year with renewed diligence and a desire to fix my wayward handwriting. As was the style, the seating plan was fixed, and I was near the back of the room. I couldn't see the blackboard. I told my parents; I needed glasses.

Indeed, I did. Dad took me off the the optometrist for testing; I was short sighted. I picked out a pair of red glasses. Spring-loaded arms; much more durable for a young active kid. My Dad had red glasses too. He wore them most of the time, although for some holidays and when golfing, Dad'd wear contacts.

I got contacts in my last year of school; I'd made the top Waterpolo Team with a 'script of -4.00D and decided it was time to see what was happening in the pool. I still only really wear them for sport. Glasses are just part of me; something I put on in the morning and take off to sleep; it's like that for the billion or so of us that have myopia.

I recently visited the optometrist and updated my glasses. It was about time too, my 'script had gone up more than a diopter in each eye; and, in old terms, it's about 20:1000+. Seriously.

Anyway, I was home from Uni one summer, looking through photos with Mum. In all the photos, Dad wore glasses. That summer, he'd started wearing contact lenses again. He hadn't worn them since 1994. He didn't want me to be worried about wearing glasses. That it was normal. That I wasn't the only ten year old with blurry vision. That I could still do anything I wanted.

I still get out bowled more than I get out caught. My handwriting is still atrocious. But I've never been self-conscious about my glasses.

It seems that the 'wonder' of medicine slowly wears off; there's a lot to be said for novelty value.

Earlier this rotation, I assisted in a Below the Knee amputation (BTKA) for sexagenarian with Type 2 Diabetes and Osteomyelitis. As it's an easy operation to explain, when my parents or friends have asked me what I'm up to at med school, I tell them about it.

The response is pretty varied, although not unexpected. Non-medical people are typically a bit 'grossed out' and think it's amazing. "Wow! You got to help cut off someone's leg?" They proceed to ask questions about blood and getting nauseous and the like. It strikes them as horrific, but also marvelous to be seeing these things. They invariably express deep empathy for the lady.

Med students and my pharmacy mates are substantially less amazed. They tend to ask about he patient's other risk factors, and then for details of the operation. "So, they were Diabetic, hey?" Some ask of the value of the teaching during the surgery. The conversation often ends with an expression of empathy for the patient.

Other doctors, of varying levels, say something along the lines of "So, you got to assist?" and "Did you find it interesting?" They're wholly underwhelmed by the idea of a BTKA. I guess it just comes with the territory. I'm certain that if they were the ones telling the patient about the treatment, their physicians' sensitivity would prevail. Of course, no-one thinks that having a BTKA is a small operation without serious life-altering consequences. But, really, that wonder that the non-medical and allied health express isn't there.

And, now that I think about it, that wonder is dimming for me too. I recently re-read My First Surgery, which I wrote last August, and I can still see the patient's face, and recall all the senses attached to it. But, when I think really hard about the patient having their BTKA, it didn't evoke the same excitement, the same enthrallment.

I have no idea how hard it would be have a BTKA. Surgery has become normal in my head.

As a kid, one of my favourite books was Louise Fitzhugh's 'Harriet the Spy'. I remember Mum giving me a copy from the library she was working at. The book was to be thrown out, because apparently, it was too old.

This was, of course, long before one of the greatest bowlers of all time took 700+ test wickets and so on. I just remember him coming across as, well, a dickhead, to my eight-year-old way of thinking. I wrote in those wee notebooks for a year or so, I think.

Surgery, thus far, has been intense and involved. I've seen patients in clinics and in the Operating Theaters, and I've been able to Scrub In on a dozen or so occasions, particularly with the Ortho Emergency List.

I didn't expect to enjoy surgery quite this much. After my experiences in Vietnam in MBBS1, in conversations with friends and family, I'd often compare surgery to football;

You play for 90 minutes for ten seconds of action, and maybe a total of four minutes highlights. The rest of the time, you're defending against a career-ending mistake.

I was reminded that football is, in fact, the world's most popular game, and not because people love to watch highlights reels. It's because every pass, dribble or tackle is about positioning before the attack. Maneuvers don't start one pass before the goal, they start everywhere. From the goalie to the midfield to the striker. About planning ahead, with some spontaneity, a deep knowledge of the opponent and strong fundamental principles. So, yeah, I like surgery.

Another part of surgery that I was, well, skeptical about is the level of patient contact. The biopsychosocial aspects that is so important in 'wholistic' care.

Last week I'd scrubbed in for a case - my last case for the day - and afterward I walked out of the theaters to pack up and drive home. I nodded to the patient's mother waiting in the corridor and ducked upstairs.

As I opened my locker to deposit my Crocs and grab my bag, I thought 'What are you doing?' I went downstairs and talked to the waiting Mum. I told her that I'd seen the surgery. That the surgeon had said it had gone well. We talked about how the patient would rehabilitate and some of the challenges. I said I'd see them both tomorrow, and headed off for the night.

It was enjoyable talking to the patient's mother. She was relieved to have some information and just to talk, I think. She was just worried about her kid.

I gave myself a kick in the butt about not talking to her sooner; that's not the kind of doctor I want to be. I saw both Mum and patient the next day, in good spirits and ready for discharge.

Recent attacks on Indian students in Sydney and Melbourne has thrust International Student relations into the limelight. Australia advertises itself as a multicultural melting pot of cultures, indeed the main two cities are known for their cosmopolitan and fresh vibe. Moreover, University students have always prided themselves on liberal, avant-garde ideals, as both active thinkers and social leaders in issues such as human rights, race and gender politics.

In the last ten years, the student political climate across both Australia and New Zealand has become markedly more conservative. Apathy is rife; University has increasingly become the domain of the upper-middle class or those with strong social supports. The illusion that university is for everyone has well and truly evaporated, but frankly, Generation Y doesn't seem to care.

International students challenge many of the aspects of these ideals, and not because of the inherent cultural differences. The cost of University in India pales in comparison to Australian International Student fees, at a quarter to a sixth of the price. Most Australian university students live at home or in their home town for university, yet students are willing to relocate from Asia, the Indian sub-continent, Canada, the United States and Africa to further their education.

In many ways, International students from developing countries represent what University used to be about; living outside of the comfort zone. Embracing independence, be it from family, financially, culturally, politically or socially comes with the experience of tertiary education.

Generation Y students don't begrudge the presence international students, but certainly the majority do not openly welcome them to campus. Indifference and apathy prevails.

Racially motivated attacks are abhorrent and shameful. Students, domestic and international should feel safe not only on campus, but in their city of residence. Australian institutions need to continue to foster strong relationships with India and the world; not only to attract both students and academics to our shores, but also to passionately reinvigorate the political and ideological diversity of our campuses.

With persistent international influence, Australia's Generation Y can begin to examine their understanding of politics. The student majority needs to be jolted out of apathy. Perhaps the thousand-person rallies in Sydney and Melbourne will cause people to question, to ask; Why?

Today I spent a few hours helping in Fracture Clinic, and I was lucky enough to see a young chap, Mike, for the second time. I was pleasantly surprised to see him again, as the Orthopaedic aspect of the surgery rotation is only two weeks. As with 95% of patients under the age of 17 with a FOOSH injury, he'd sustained his skateboarding.

I got talking with both he and his Dad. After we covered the usual follow-up stuff, prognosis etcetera and the Consultant had breezed in and out, the father asked about Med school and the oft asked "What do you want to be when you finish?"

And, as usual, it's a challenging question to answer. I posted a while ago about some possibilities, and I know which ones I really like, but, well, it's all so far away. And really, few patients actually ask the question with a deep, driving interest about my further specialty.

So I said to Mike, do you remember at Primary School, how you thought you were old and king of the school and that you knew everything? You were bigger than the other kids, and they all looked so young and small to you, right?

And then you went to High School. And on the first day, you feel like a baby. All the big kids are huge, they're not only faster and cooler than you, but they know everything. They know how school worked and where to go when you wanted to muck around or if they want to do something which teacher to talk to, yeah? Okay, cool.

Well, Med School's like Primary School, and I've got a year and a half to go.

Dawn, Whitehorse Mountain Lookout, QLD

I posted a wee while ago about how Life is Beautiful, and the importance of taking a moment to relax. A few mornings ago on the way to work, I was running ahead of time. As the sunrise was looking nice I took a some time to scamper up to a lookout not far off the beaten track. I had my new camera with me, and I managed a few shots of both the Sunrise and the Lookout. It was a wonderful way to start a long day's work, and I felt fresh for hours!

The camera was a present from a good friend a few weeks ago, and it's going fantastically well. Here are some more shots;

Womblescope

Mangrove Glare, Nudgee Beach, QLD

The Dead Noon, Rockhampton, QLD

Washed Out Cranes, Kedron, QLD

Watching The Time

The round of golf had started awkwardly enough; we had planned to play as a foursome, but at the last moment one of the chaps had elected to bring along his wife, and being as it was relatively social golf on a quiet course on a Sunday afternoon, we bit the bullet and played as a five.

We were horrendously slow, and I recalled my parents' and gradfather's conversations about the frustrations surrounding playing as a five. It didn't help that the average handicap was greater than twenty. Nonetheless, after four hours the light was fading and we had made it through twelve holes. We were all tired, and had throughly ruined a short walk with plenty of shots.

The thirteenth was the kind of length that's a par 4 for men and a par 5 for ladies, with the ladies' tee some forty metres behind the gents'. The lady among us was certainly the most tired, and flatly stated that she "Couldn't be f%^ked walking that far back." So, we teed off in turn, and she was to hit last. Four drived sailed in the general direction of the fairway, before she'd stepped up to the tee.

Her shot was credibly straight. It was, however, also a 'worm burner' or 'ground grubber'. It ploughed into a raft of ducks pottering in front of the tee.

The ducks scattered, their fat white-feathered abdomens flying low across the fairway. One remained.

Its neck was broken. It tried to fly away, but merely succdeded in flipping itself onto its back, with head and broken neck lying underneath its body. It tried again to fly away, and the same thing happened. It was panicking. It was dying. The duck kept flipping. It was sickening to watch.

Two of the group had promptly marched up the fairway to find their wayward tee shots. They weren't interested in the animals. The lady had gasped and begun to cry. She was pretty fazed by the flipping, dying duck. I said to her hubby, "We need to do something."

One of the unharmed ducks flew back and waddled over to its dying friend. It got to about a metre from the flipping, whirling body and was scared into flying off.

We decided that the duck needed to be 'put out of its misery', and I was tasked wtih delivering the fatal blow. I softly walked to within range, and the duck went ape. The neck was visibly snapped and loose, and it flicked and flew about like a lamb's tail. The duck's eyes spun and gurgled and sparkled.

I felt sick to the stomach. I hit it across the head. It lay still.

Then, it tried to fly away again. I was mortified. I wasn't sure what to do, because the duck had again started to flip and whorl on the spot. I felt even more nauseus. I aimed carefully, and hit the duck again.

It lay still, eyes grey. The head lay twisted, protruding from under the body, bloody with beak open.

I wiped the club on the ground, and returned it to its owner. I went back to my gear and walked the hole in a daze. I had just killed an animal. Essentially and ultimately, my choice had hastened it's death.

I knew it'd been the right thing to do, but it was still awful. I wasn't in the mood for any more golf. I wasn't keen to hit anything else at all.

I think, in retrospect, that I wouldn't have been so upset if I'd only had to hit it once. But, given that the first blow was ineffective, another was necessary. The choice had been made and needed to be followed through.

Although this story lends itself to all kinds of 'end of life' and ethical issues, I've also been thinking about it regarding undesireable outcomes. What happens if a surgery doesn't work? What plans are made for a failed therapeutic outcome?

The duck's end was final, the endopoint unalterable. But that's not always the way. Taking a knife to someone's a risky procedure and not to be taken lightly, of course, nor is the illness in the first place.

There's often talk about surgery being reliant on a positive, confident mindset from both patient and doctor. The whole, 'Do it once, do it right' credo. But, gee, it's pretty awful to be confronted with a worse situation than when you started. How the hell do you get a patient to truly comprehend that?

My boss came in when I was working the other day, and we had a good chat. I told him that I was having a relatively unenjoyable day, and he asked why. I thought to myself, hmph, the times, they are a-changing.

I mentioned a few trivial things that had frustrated me a little, but they certainly weren't anything out of the ordinary for a pharmacist to deal with on a weekday. Eventually, I cut to the chase, and said;

'Today's the first day since pre-reg that I don't want to be at work. I know I don't work a lot, but usually, once I'm here, I revel in being at work. I like helping people out, I like the staff, and usually the bureaucratic crap that's a pharmacist's bread and butter, is well, bread and butter. But today, well, today's a day that I'm thankful that I'm doing Medicine.'

I've been spoilt recently; I'd only worked once since Easter, and at SQuIRT there was always time between patients to take a deep breath behind a closed door. Pharmacy can be a bit of a stage when the store's ten-deep, and for the first time in a long time, I didn't feel like performing.

Of course, it's all a frame of mind. I'm not so deluded as to think that Pharmacy and Medicine are at opposite ends of any spectrum, I just hadn't mentally prepared for a long and arduous day's work. My mindset wasn't about hard work, and I think, on that day I showed up with cash in mind. Instead of thinking about each person and their problem or question, I battled through the day. I fluffed around on the computer, and was getting by on my basic levels of 'giving a crap', allowing each small annoyance to add up, instead of letting it slide the way I normally do.

I went home feeling pretty disgusted at myself. Even though in the words of the Beastie Boys, I got the skills to pay the bills, I didn't get into Healthcare for the money. It's just a handy byproduct of actually doing my bit in the community, once I've covered the essentials.

I don't want to have another day like that, either in Pharmacy, or, when the time comes, in Medicine. I'm in healthcare because people get sick, and they need something. If that's confirmation that it's okay to give panadol and antibiotics, fine. If that something is a bandaid, fine. If that something is surgery and a week of inpatient care, fine.

I will do my best to play a role in that care, where I can.

I will not sit at the dispensary computer browsing Facebook when there are patients in the store.
I will not be a Newspaper pharmacist like the ones I used to berate.
I will pay more than a passing interest in the mire of Panadeine Extra and Cold and 'flu tablets passing through my hands.
I will be nicer to the methadone patients; I will eat the bread and butter.

I will talk to more of my elderly customers, I will not think of them as LOLs in NAD.
I will take greater pride in my work.

I will remember why I love pharmacy. I will not let my sense of optimism and hope that shines through every other aspect of my life be dulled when I go to work. I am too young to allow blemishes of cynicism win out over optimistic realism. It's not my style.

I have twenty months left as a Pharmacist, and crikey, in that time, I'm gonna be interested in my job. Because when I stop being a Pharmacist, I'll stop as a damn good one.