Tuesday, November 12, 2013

Two Weeks in Renal Medicine


Let me start with a bit of introduction on how year 5 in U.o.Manchester is structured.
First of all, we have 8 blocks altogether - each block is 4 weeks.
Blocks 1-4 is before the exempting exam while blocks 5-8 is obviously, after the exempting exam but before the final exam.

What's with these two exams?
Well, an exempting exam is in January and the final is in June.
If you pass the exempting exam in January, then as the name implies, you are exempted from sitting for the finals in June.
That means, if you pass the January exam, you are pretty much in your honeymoon months from Febuary onwards. If you don't, you bury yourself in books and stethoscope, sometimes with a tendon hammer or fundoscope and try to put everything into your brain, revengefully while the bulk of your friends enjoy their blocks 5-8.
Clear on the exam bit?

Now let's get to the blocks per se.
Blocks 1 - 4 are the blocks in which you will do ONE community block; that means you are gonna travel to a GP surgery (basically klinik kesihatan in Malaysia) and see patients on your own and try to make these poorly people well. The other two blocks are in the hospital and one more block is an OSS (and I can't remember what it stands for). Anyway, OSS block is the block where you revisit all the skills you've learnt for the past 5 years (wow) such as poking needles into patients, sticking a catheter up their urethras (that's where people pee from), perform blood cultures etc etc. On top of that, the OSS block is also your Oncology block (that is what the "O" in the OSS mean).
So juniors (if any of you ever read this), you'll know roughly what to expect.

After block 4, is the winter break (read: crazy last two weeks b4 finals). And then the Jan exam.

Blocks 5-8 are hopefully, my honeymoon months. I really hope I can pass this exempting exam (which will be in 58days time!)
So out of these 4 blocks, 2 will be elective blocks ie you can go anywhere in the world to help doctors save ppl or, you can do what I will be doing, go back to Malaysia and enjoy life as a medical student in a Malaysian hospital before coming back to work as a junior doctor.

One more block is a Student Assistantship, which basically mean you are gonna shadow a FY1 (the most junior doctor in the hospital) and help him/her with everything so that you can do his/her job when you start working. It doesn't really apply to me since I am not going to work here in the UK but I think it'll be a good exposure to know the system in and out. The other block could be another hospital or a community block, just like in blocks 1-4.

So for my fifth year, my blocks allocation are:
Block 1: Endocrinology (Hospital block) in Royal Blackburn Hospital
Block 2: Community (in Accrington. The bus fare cost me £51 per month and two hrs of journey everyday)
Block 3: Renal Medicine (which is the block I am in now)
Block 4: OSS


Block 5&6: Electives in Malaysia woohoooo!!
Block 7: Student Assistantship
Block 8: Hospital (cant remember what exactly)

Blocks 1-4 can be switched around, you may start with OSS and end with Community etc.
Same goes with blocks 5-8. That means you will nvr do electives before the exempting exam in January.

As I've said earlier, I am in block 3 (already third week now!) and I am doing Renal Medicine.
Guess what, my first day in this block was in a Renal Clinic.
And within that one morning, I know for sure I do not want to do Renal Medicine for the rest of my life. It is definitely one specialty I am going to avoid specialising into. Last year, we were asked to rank the blocks we'd like to do for fifth year and I think I put Renal Medicine as my second choice. That was because my mother has diabetes and I know it inavariably affects the kidney so it WAS always the specialty I consider. But after that first clinic, the interest and consideration went down the line. There is nothing wrong with my supervisor, NO.
It is just the fact that a Renal Medicine specialist could not do much for the patients. Kidney is just so important that when it goes, we cant really do much anymore. But because our kidneys are very good, we can lose about 60% of the function before they pack up.

You see, chronic renal failure (that is the failure of the kidney that happens over a long period of time, most commonly caused by diabetes and hypertension) is divided into 5 stages according to the severity.

Stages 1 to 3 can be managed in the community, means any doctor can deal with it with the patient coming over yearly or 6-monthly for health review. But at the same time, optimise diabetic or blood pressure control to slow down the damage to the kidney. Most of the patients will not progress further.

When it reaches stage 4, the guideline in UK recommends referral to a Renal specialist. I don't know at what stage do the doctors in Malaysia refer a patient with chronic renal failure (CRF) to the specialist.
And what will the specialist do? Not much, apart from keeping the diabetes and the blood pressure in tighter check. Well, most commonly CRF is caused by these two culprits. If it caused by any other diseases, then it will be a diff story.
Since the patient is now in the specialist's renal patient list, any deterioration of the patient's condition can be acted upon faster. Ultimately, when the kidney fails, we will be looking at either dialysis or renal transplant.

Hence in the clinic, patients will come in with a creatinine level of 280 (the normal level is less than 100), and the doctor will not be surprised, because the patient has been having a creatinine level of 260 and 270 all these years (remember the renal failure is already stage 4 when the patient is referred). Hence, the doctor is going to do the usual examination of the abdomen and BP la and everything and really2 monitor the medications the patient is taking (since so many meds can effect the kidney) and stop/slow the kidney damage. Hence a specialist might see the same patient for many many many years monitoring his/her renal function all the way, without actually treating it because we can't cure diabetes or hypertension.

That idea of seeing the same patient for 10 years but not being able to actively do something for him/her apart from keeping an eye on his/her renal function two or three times a year does not appeal to me, at all.

As a dramatic and active person, I would love to see my patient get better and not just monitoring them waiting for the kidneys to pack up, on one bad day in the future.

They say Orthopaedic Surgeons are very proud of themselves because their patients come into the hospital having broken their bones in an car accident or something and under their care, the patients can then literally walk out of the hospital. So I think literally, the patients of an Orthopaedic Surgeon will have the greatest improvement in their physical appearance, from a bent, bleeding almost crushed leg to an almost perfect leg (in a lot of the cases).
But no, I am not going into Surgery :)

'til then,

-Because life is a test-