August 18, 2015 § 3 Comments
As I look back on the
days weeks that have passed since my last post, I realize that I have no idea where to start, what to write or how to write it. I’ve written before that I like to write when I feel reflective, so that the thoughts simply flow through my fingers onto the keyboard. These thoughts usually come together as I write, but so much has happened now that I can’t seem to bring everything together. So much to share and so little energy to figure out how to share it!
We’re two weeks into our jobs at hjemmetjenesten and feeling absolutely exhausted. So far this month, we’ve only had one day off each and we only have one or two more before we leave for Budapest.
Our internship at the hospital ended on more of a sour note. Working in hjemmetjenesten is such a different experience and it really puts our time at the hospital into perspective. On the very last day one of the department heads asked Skjalg to share his thoughts on the internship. He said he’d learned a lot and that he felt he had a much better idea about how the department is run, but that he wished there had been more guidance and some sort of orientation in the beginning. “What? You weren’t called before you started?” the doctor had asked. As it turned out, students are normally contacted before the beginning of the internship and given a sort of introduction/orientation to get them started. The person responsible for this was on vacation at the time and the person acting in his/her stead was apparently not quite as organized. So, on our very last day, we learned that we’d fallen through the cracks. A bit discouraging to say the least..
On top of this, we had a heavy experience with one of the heads of the surgery department. As a part of our curriculum, we have to complete summer practices/internships within various departments. First was nursing, this year was internal medicine and next year is surgery. We want to secure a place for next summer as soon as possible, so we’d figured we would contact the surgery department during that last week.
We spent maybe an hour trying to find the right person to talk to. When we did, Skjalg went into the office where they were having their morning meeting and I stayed out in the hall. Skjalg was in there for maybe 15 min. I could hear that people were talking and doctors and nurses kept entering and leaving the room, but I had no idea what was going on. When Skjalg came out, his facial expression was a sort of amused shock, that kind of shock when something is so unbelievable that you laugh it off until the anger sets in. “That was everything that you never want a doctor to be,” he said. “I need to sit down and process this”.
We headed back to the office designated for medical students and plopped down on the couch in one of the small rooms there. Skjalg began describing the experience and his words sucked whatever happiness I’d had that morning right out of me. Afterwards, we sat there in silence for what felt like hours. Once we’d had some time to process, Skjalg asked me what I wanted to do. “The weak part of me wants to go home and just curl up in bed. But that’s not going to make this any better. The strong part of me wants to prove them wrong,” I said. Skjalg felt the same and we decided to go down to the emergency room like we’d planned. It ended up being really slow there, so we asked one of the nurses to teach us how to perform a peripheral venous cannulation and then we spent an hour or so practicing on each other before going home. At the next morning’s meeting, we saw that only one patient had come in that whole day, so we didn’t miss out on anything other than a few hours of awkwardly standing around.
At this point, you’re probably curious about the details of the exchange between Skjalg and the head surgeon. That evening, Skjalg sat down to write out everything he could remember in an email to the hospital’s administration. He received replies from HR and the director within several hours, both offering their sincerest apologies and saying that our applications were very welcome. Here is Skjalg’s email:
Today I went to the surgery department and spoke with one of the department heads there about a surgery practice spot next year. The exchange went something like this:
S: Hei, jeg ville gjerne høre om mulighetene for å ordne seg hospitant plass neste sommer. (Hi, I was wondering about the possibility to apply for a position for my surgery practice next summer.)
D: Oja, nei det vil vi aller nødigst gi dere. Dere utenlands studenter kommer jo bare å skal ha signatur. (I see, well, we would rather not give you that. You foreign students only come here for the signature.)
S: Hva mener du med det? (What do you mean by that?)
D: Jo, det blir jo at vi bare signerer uten å vite hva dere har gjort, bare rot med dere. Også er det jo sånn at de norske studentene må gå først. det blir jo idiotisk om vi gir dere fortrinn forann de som går i Norge. (Well, what happens is that we sign something without knowing what you have done, just a bunch of nonsense with you. Also, Norwegian students should be considered first. It would be idiotic for us to take you ahead of those studying in Norway.)
S: Så det er umulig for oss for å få plass her? (So it’s not possible for us to get a spot here?)
D: Nei dere kan jo alltid søke. Men en annen ting er jo at det bare er tull at dere er like godt egnet som de norske studenter som avtjener turnusstilling. De har jo mye mer praksis og er derfor bedre egnet. Jeg tror nok at disse utenlands studiene forsvinner snart tror du ikke det? (You can always apply. But another thing is that it is nonsense that you are as equally suited as the Norwegian students doing internships. They have much more practical experience and are therefore better suited. I believe that these exchange programs are going to disappear soon, don’t you agree?)
S: Nei, det tror jeg i grunnen ikke. Ikke så lenge norske universitet ikke utdanner nok leger til å møte behovet. (No, I don’t think so. Not so long as Norwegian universities continue to educate less doctors than are needed.)
D: Vi har jo altfor mange av dere utenlandske studenter. Det er jo overflod av italienske leger som går arbeidsledige, selv om mange av dem er kvinner som bare vil være hjemme, Det er jo snakk om patrialsk samfunn der. (We’ve got too many of you foreign students. There’s an abundance of Italian doctors without jobs, even though many of them are women who just want to be home. We’re talking about a patriarchal society there.)
S: Nå tenker jeg at vi er da norske studenter som studerer i utlandet fortsatt. Vi skal alle inn i samme arbeidsmarkedet til slutt. (The way I see it is that we are Norwegian students studying abroad. In the end, we’re all going to enter the same work field.)
D: Det kan hende, men jeg liker ikke at alle som helst kan dra til utlandet å kjøpe seg et artium. Men det er heldivis ikke jeg som ansetter turnusleger, der er det mange som også har gått i utlandet. (That may be, but I don’t like that jut anyone can go abroad and buy themselves a degree. Luckily it’s not me who hires residents, many of them have studied abroad.)
S: Det syntes jeg var veldig diskrimenerende sagt, Det er da ikke sånn at det er bare skoletapere som velger å dra til utlandet å studere. Vi er mange som kunne kommet inn på studiet hjemme men valgte å reise til utlandet for å få en bredere erfaring samt og oppleve litt av verden mens vi studerer. (I find what you’re saying to be very discriminatory. It’s not the case that it’s only those who couldn’t get in here that go to study abroad. There are many of us that could have studied here but chose to study abroad in order to have a broader experience and experience a bit of the world while we study.)
D: Neida, det var kanskje satt litt på spissen, du er sikkert både en snill og flink student du. (Well, I was perhaps a little blunt, you’re surely a nice and clever student.)
S: Takk? (Thanks?)
D: Dere får bare sende meg en mail med søknad da. Så får vi se. (Just send me an email with your application. Then we’ll see.)
S: Ha det bra! (Goodbye!)
Jeg håper virkelig ikke at slike holdninger er utbredt i helse-norge, og at dette var unntaket ikke regelen. Uansett så var det var utrolig nedslående å få høre at man er mindreverdig fordi man valgte å studere i utlandet. Jeg er veldig stolt av utdanningen min, og mener at den er minst like bra som den jeg kunne fått hjemme. Samtidig er jeg fortsatt glad for at jeg valgte å dra til ungarn for å studere. Det er et flott studentliv som jeg ikke kunne hatt i Norge og jeg har blitt kjennt med folk fra hele verden. Ingen burde se ned på dem som har valgt anerledes enn dem selv. Vi har valgt en annen rute. Men destinasjonen er den samme. (I really hope that such attitudes are not prevalent in the health industry in Norway and that this was the exception, not the rule. Whatever it was, it was incredibly discouraging to hear that you are inferior because you chose to study abroad. I am very proud of my education, and believe that it is at least as good as the one I could have had at home. I am still glad that I chose to go to Hungary to study. I have an amazing student life there that I could not have had in Norway and I have made friends with people from all over the world. Nobody should look down on those who have chosen differently than themselves. We have chosen a different route, but the destination is the same.)
After reading this, it’s easy to see why we were so strongly affected in that moment. We’d felt a bit ignored during the internship, save for the handful of good teaching moments, and this was exactly the type of mindset that we’d hoped we wouldn’t encounter. We’re fully aware of the prejudices that come with studying abroad, but remain very proud of the education that we are receiving. There are always going to be people that have different experiences and thus different feelings, but both Skjalg and I – and the friends we hold in close company – feel our education is thorough and demanding and preparing us to be great doctors. Every school is different and I don’t feel it is fair to pass judgement on students based on what one thinks one knows about a student’s education. For example, Skjalg was talking with a fellow medical student at work (hjemmetjenesten) about anatomy finals. This student studies in one of the Scandinavian countries and said that for their anatomy final exam, they sat together as a group of about 10 students around a large table and discussed anatomy with the examiner for about 15 minutes. At the end, they all passed (no grades, only pass/fail). A bit different from our anatomy final, which lasted 5 hours and included 3 parts with 3 different examiners.
I’ve had moments like this before. It’s amazing the power that some words can carry and how thoughtless – and incorrect – people can be. There are two moments that I remember really well. I’ve written about both of them in “My Story” and can repeat them here:
When I was 17, fresh out of high school and working at CPK:
While the whole Navy thing was going on, I was working at a restaurant chain called California Pizza Kitchen. I moved up pretty quickly, beginning as a hostess, then a server, and then was a trainer within 3 months. I was learning a lot about life, how to support myself, how to be a leader and function in the “real world”. (I had worked all through high school, from the summer I turned 15, but it was an after school/weekend job.) During this time, I struggled with the actuality of not being in school. I felt like I was letting a lot of people down. Some counselors at my former high school had even told me that I was a bad reflection on them. It didn’t matter that I was working hard to get there, only that I wasn’t there already. Once I started sharing my plans with people, I got much more supportive feedback.
One of the most harsh moments was actually when a girl I had taken AP Biology with came with her family into the restaurant where I was working. They sat, of course, in my section. Everything started out fine, everyone was really friendly, until her dad arrived. She introduced me, saying that we had gone to school together, to which he replied,
“All that money and all that education – and you’re working here?”
Truthfully, I was so shocked that I don’t recall exactly what happened afterwards. I think I tried defending myself – to no avail – and leaving as soon as I could. I think the girl might have talked to her father so that when I came back, I received an apology. I was so hurt that someone could not only be so cruel, but also so entitled. Even if I had chosen that path, he was in no position to judge my decision to do so.
When I was 21, living in Los Angeles and had just made the decision to move to Norway and start over:
After getting off the phone, I headed to physics class, smiling the whole way. I was blissful during the first half of class until break, when a friend in the class, who’s husband was a doctor, told me something that I was not prepared to hear. She had been witness to my struggle during the semester and understood what I had gone through to get to even that point. When I told her the decision I had just made, she told me:
“What? That’s a horrible decision. That’s honestly the worst decision you could possibly make! You can’t do that. If you do that, you’ll never be a doctor. You’ll go over there, waste a bunch of time and never get to where you want to be.”
I can’t imagine anything more damaging to your self-esteem than when you’ve committed yourself to making a big decision in your life and the very first person you tell bats it down without hesitation. When talking to my mom later that night, I told her about what my friend had said and she told me something I will never forget, something that I remind myself of almost every day:
There are always going to be people who react to any deviation from the common path. They are going to cut you down, tell you that you’re not going to make it, that you are going to fail and regret your decision. They are going to tell you it’s wrong because they are scared. They are scared to think that there is another way to do it. That you know something that they don’t. They will question themselves and wonder why they didn’t think of it first. And the only thing that will comfort them is telling you that you are wrong.
It’s hard to not let these types of comments get to you. They usually come when you are in a state of transition and one of the quintessential aspects of that state is vulnerability. I feel vulnerable a lot – and I really mean a lot! New classes, new teachers, new exams, new patients, new diseases, new treatments, new challenges that come with living abroad, new summer practices to apply for, new hospitals to work in, new coworkers to meet.
I felt so nervous before our first day of our internal medicine practice and possibly even more nervous for my first day working in hjemmetjenesten. I think part of it has to do with everything being new – and therefore challenging – and part of it has to do with language. Having to speak Norwegian all day makes me feel quite limited. I’m able to speak to coworkers and patients just fine, but I still have yet to feel like myself in Norwegian. I notice that there are quite a lot of times I don’t say something that I would have said had we been speaking English. With English I’m so much more sharp and open. With Norwegian, I spend my energy translating what I’ve heard, thinking about my response, translating my response, adjusting my response to fit cultural standards and then modifying my accent to most closely resemble a Norwegian dialect. By the time I’ve done that, the conversation has moved on and my brain in focusing on something else, or 50 other things simultaneously, which it often likes to do. Hopefully it will be different once I’m here for more than 1-2 months of the year.
That said, I survived everything I was nervous about! The internship is done and over with and I’m feeling better about work with every shift. One thing that has been really helpful for me is having to meet and speak with so many new people. This summer, I think I’ve met at least 200 people – between the hospital, restaurant and hjemmetjenesten – which means 200 times practicing how to introduce myself. I’m less insecure about having a slight accent when I speak and no longer cringe when I completely butcher a sentence. It’s actually helped me show my personality a bit more and forced the Norwegian version of myself to toughen up a little bit.
Enough of a catch-up for now – I’ll be back!
July 27, 2015 § 2 Comments
We’ve reached our last week of internal medicine practice and I’m looking forward to the change of pace that awaits us from next week. It’s been a rich learning experience and I feel so much more secure now that I have some hospital experience here in Norway.
From next week, Skjalg and I will be working in “hjemmetjeneste”. This is a government service that provides home care for patients, such as giving medication, making food or aiding with personal care. The number of visits a day for a single patient varies depending on their needs. In addition to the shifts in hjemmetjeneste, we will be working at the restaurant. Skjalg’s stepmom will be heading back to Thailand to visit her mom, so it is likely that we will need to pick up some more shifts. It’s going to be a tough month for us, but it will be really nice to fill in the financial hole created by the exchange rate this past year (we have to pay our tuition in dollar and our rent in euro and were hit quite hard this past semester).
Our schedule – without the extra restaurant shifts – for the next 5 weeks! Day shifts go from 7:30-15:00 and evening shifts from 15:00-22:45.
Our time here at the hospital has been nice but we’re ready for a change. Since the first week, things have become quite monotonous. We start every morning in the large conference room where all of the doctors from the different departments meet and discuss new patients. Depending on the number of patients and associated discussions, this can last anywhere from 20 minutes to an hour, though usually closer to 20 minutes. After this, we head to our respective departments and sit down for more meetings.
The first is a meeting with all the doctors on the shift to discuss the patients. I find this really interesting (what I’m able to follow at least). A large projector displays all the necessary patient information, including lab values and any notes/referrals. There is also a program that shows any imaging results, CT scans, MRIs, X-rays, etc. One of the doctors told me that they like to be at least two when making a decision about a patient and prefer if they are three, with the third coming from a different department. I have to say that I am really impressed by the level of communication here.
During this meeting, the names of different medications are constantly brought up and discussed. We haven’t taken pharmacology yet, but I still want to get something out of it. My solution? I downloaded an app for felleskatalogen (catalog of pharmaceuticals in Norway) and look-up the various medications as they discuss them. I can also save the ones I look up to a list so that they are easier to find. The profile of each medication is extremely thorough and there is even an option to check the effect of medications on each other.
Following the doctor’s meeting, the doctors for each group (patients are divided into two groups by color, i.e. red and blue) meet with the corresponding nurse. During this time, they discuss the patients in more detail. The doctor usually asks how the patient has been doing, how they have been interacting with the nurses and if there is anything that stands out. Then they update the nurse on what was discussed at the earlier meeting and begin to discuss further treatment. This is usually over by 11:00/11:30 (depending on the doctor and cases) and after that, the doctors go to visit each of the patients.
After spending an hour or so visiting the 5-6 patients in the group, it’s time for lunch. At this point, I head up to grab my lunch from my locker in the medical student room. Well, sometimes. Usually I stay in the department until it’s time for me to go home, just so I don’t miss out on anything. The reason for this is that after lunch, the doctors sit down to paperwork. This is the time during which I can get lost in the shuffle. If there is something happening, you can bet I’m there! Otherwise, the doctors don’t seem to enjoy having a medical student staring over their shoulder….
One day, Skjalg and I took a patient for an echocardiogram. The doctor was in training, so she was good about describing the whole process for us. When she was done and the head doctor came in to check the results with her, Skjalg and I were allowed to continue examining the patient for our own benefit. The patient had chronic kidney failure and the doctors in my department suspected him/her of having amyloidosis. They were doing the echo to see if they could find any morphological changes in the heart. Amyloidosis is a disease where protein is deposited outside the cells in various organs/tissues. There are several types depending on the type of protein and this patient was suspected of having the age-associated type, senile systemic amyloidosis. When it was time for us to take the patient back to our department, the doctors actually thanked us for showing interest. I found this so surprising because to me it’s obvious that we are interested – we should be! It also made me wonder about what other students are like…
On another day, I got to see a kidney biopsy. I’ve never seen one before and am still so in awe about how it was done. For some reason, I had it in my head that it was more invasive and the sample much larger than it actually is. The patient lay on his/her back and the doctor visualized his/her anatomy via ultrasound. Then, once all the necessary sterile preparations were in place, the doctor attached a spring-loaded needle to the transducer and located the ideal point for the biopsy.
The patient was instructed to hold his/her breath (to stop the organs from moving with respiration) and the needle was engaged and in and out within a second or two. The sample was washed out of the needle with saline solution and then quickly examined by another doctor using a light microscope to ensure that the sample was sufficient (in the case of a kidney biopsy, they had to ensure that there were enough glomeruli to perform an accurate diagnosis). Meanwhile, 2 or 3 more samples were taken from the patient.
Once the samples were confirmed, we ran them over to the pathology lab for further processing.
To maximize this last week, our plan is to spend at least two days in the emergency room, if they’ll have us. I regret that I haven’t spent more time there because it seems like there is so much more to do. Since I’m assigned to the kidney department, it hasn’t felt right to run off to the ER if there is something that I could there. But knowing if there is going to be something to do or not has been challenging! Instead, my days have been: attending four or so hours of meetings, going on rounds and then joining anything possible in the afternoon. By the time I’m done there, it’s almost a bit too late to head down to the ER (we’re supposed to finish around 15:00/15:30).
Now that I’m 3 weeks in and feel more comfortable here, I realize how little of an issue it would have been to just go whenever I want. There isn’t really any structure here, at least in my personal experience. I’m assigned to a department and I follow around whichever doctor will have me (usually the most senior doctor) and if I’m not told that I can join anything that day, I’m kind of on my own. I’m at a level of my education where I’m just not very useful. Once we have taken pharmacology (4th year) and have more clinical practice (4th and 5th year), we’ll be able to do a lot more. As I wrote to a friend earlier today, I’ve learned two things during this past month: (1) we know a lot, (2) we know nothing.
As you can probably tell, I’m currently in a mixed state of satisfied and disappointed. I wish there had been a bit more structure and guidance, but at the same time understand that this is not always possible in this environment. There have been good teaching moments sprinkled throughout the practice, for which I am very grateful:
- One of the doctors, Dr. J, was a great teacher when he wasn’t busy. He taught me about different types of dialysis and even sat down with me for 20 minutes to explain the exact mechanism behind peritoneal dialysis – with drawings and everything. Despite his many years as a doctor, he’d retained his ability to think like a student and would often explain things in list form with plenty of theoretical details. Unfortunately he went on vacation after the second week, so I didn’t have much time with him.
- Another doctor, Dr. T, was in a teaching-mood one morning and explained the importance of each of the lab values as we went through them. I furiously wrote these down and then properly answered a question when I was pimped by Dr. J a few days later. The question was, “What is the reason behind the increased leukocyte count?”, to which I answered, “Treatment with steroids”. I didn’t execute my answer very well though. I wasn’t sure that I had the right answer and mentioned that I thought I’d heard Dr. T say it earlier that week. Dr. J said I was right but joked that I’d cheated. Another doctor, Dr. Q, then asked if I knew the mechanism behind it. When I shook my head, he explained that steroids decrease the expression of the adhesion molecules that enable leukocytes to exit the blood into the interstitial space. So, there are technically the same number of leukocytes in the body, but more in the blood because they are stuck there. Pretty cool!
- Last week, we had a doctor in (for just the day) who constantly asked me if I had any questions. This was really nice because I tend to write down things I am curious about, look them up later and then if I don’t find anything I ask. While we were waiting for the nurse to come for the doctor-nurse meeting, he pulled up a random patient’s EKG on the projector screen and told me to diagnose it. I was a bit flustered, since we’ve learned everything in English, but was pleasantly surprised at how quickly it all came back. My analysis was a bit bumpy – mainly because the speed is different (Norway uses 50 mm/min, whereas the rest of Europe 25 mm/min) – but I got it right in the end: acute right myocardial infarction.
A last experience – and an extremely valuable one at that – came with yet another new doctor, Dr. P. (Since it is summer and most Norwegians take their vacations during summer (Norwegians have the right to 3 weeks of vacation during the summer and 2 weeks outside of the summer), the doctors in the department have changed almost every week). One of the patients in our department is terminal and Dr. P had to set up a meeting with his/her significant other and sons to inform them there are no more options for treatment. The patient, whom we can call Blue, suffered for a long time with chronic kidney failure and received a kidney transplant last year, which unfortunately didn’t go well. Blue ended up with an infection and has been on a downward spiral since then.
The meeting ended up being three: one with Blue’s significant other, one with the most involved sons and one with the others (who were on vacation during the first two meetings). Each of these meetings lasted at least an hour long – which left me pleasantly surprised! I was present for the first two so that I could witness first-hand what it is like to deliver bad news to a patient’s family. I feel so lucky to have had that opportunity, as Dr. P has an especially good bedside manner. I’ve been on several rounds with him now and really admire the way he talks to the patients. He’s the kind of doctor that I hope to be one day.
That’s enough for today! Hoping the rest of the week goes smoothly, maybe with a few bumps for learning’s sake 😉
P.S. My stats page shows me which posts are read that day (not who or when). Someone looked at this one today – Perpetual fluctuation is the essence of the perpetual universe – and I’m so happy they did because it was just what I needed to “hear”. Such a treat to be able to look back like this! More than two years ago…so much has happened since then!