Royal Blackburn Hospital

Now that I have finished both a psychiatry core rotation at the Royal Blackburn Hospital in the UK as well as a psychiatry sub-internship elective rotation at Mt. Sinai Hospital in Miami, I’ve come to understand the main similarities and differences between the practice of psychiatry in these two locations. While the diagnoses and treatments are more or less the same in both the US and UK, the approach can be quite different. Nevertheless, in both countries, I have had really good learning experiences, and absolutely love and look up to the doctors I rotated with, who are all professional and passionate about what they do.

Disclaimer: I can only speak about my experiences at these two hospitals, Mt. Sinai Hospital in Miami and Royal Blackburn Hospital in Blackburn, England. There may be wide differences in the approach to healthcare among different hospitals within the US as well as the UK, which I cannot address here. I also cannot speak for which system is “better,” but only what I can learn about patient care as a student from these two systems.

Ward Rounds

In Blackburn (UK), the doctors dedicate about 30 minutes to an hour seeing each patient during ward rounds, and they see each patient once or twice a week, 4 patients per day. The encounters take place in an interview room, and each patient is scheduled to see the doctor one at a time. During the ward rounds, the doctor, social worker, nurse, secretary, (and the medical student), and any other professionals involved in the care of the patient are present in the room. Before the patient comes in, everyone in the room usually has a discussion, getting updates about the patient to make sure everyone is on the same page with the patient’s care. Then, the patient comes in and the interaction is usually between the doctor and the patient (and/or the patients’ guardian or caregiver). After the patient leaves, the doctors, nurses, and social workers have another discussion over the encounter that just took place and discuss the next step in the plan. The entire encounter may take up to an hour for each patient.

Because of this scheduling in Blackburn, I saw the doctors conduct very thorough interviews with the patients during the ward rounds and as a student, I learned a lot about the patients’ lives as well as how to do very thorough psych interviews. It was also really good to see how doctors, nurses, and social workers work together as a team to provide care for a patient. Because each doctor only sees about 4 patients per day, I also found that the doctors had more time for students and are very willing to teach students one-on-one. It was not uncommon for my attendings in the UK to sit down with me and teach me about risk assessment or psychosis for an hour or two. I feel that I learned the fundamentals well because of these one-on-one teachings I got from the UK.

On the other side of the world, here in Miami, the approach to psychiatry is much different. Here, the doctors see patients for only a few minutes each day during ward rounds, and usually without social workers or other members of the care team present. But despite the short contact with the patients, the patients are seen nearly everyday by the doctor. On an average day, the psychiatrist here in Miami sees about 20-30 patients per day, but only spent about 2-3 minutes with each patient. Rather than having the patient scheduled to come into an interview room at the ward of the hospital to see the doctor and the care team (like it is in the UK), the doctor-patient encounters in Miami are not scheduled. Rather, the doctors here go into the patient rooms to see the patient, who are often in bed or sleeping, and often with the TV on. Most of the patients here also have a roommate (whereas in Blackburn, every patient has a single room). I found it often difficult to assess the appearance and mood of the patient in this setting as the patient was often drowsy from just being woken up by the doctor or distracted with a TV or roommate in the room, and not in the patient’s regular state of mind. I find the patient encounters in the UK much more orderly and controlled when compared with my experiences here in the US.

As I mentioned before, here in Miami, there’s usually about 20-30 patients to see per day. Because there are so many patients to see in a day, students here in the US often contribute more directly with the patients’ care by helping out the doctor in seeing patients during ward rounds and writing patient progress notes (under the doctor’s supervision). Often here in Miami, I was assigned patients to see and evaluate by myself, present my findings to the doctor, and fill out the daily progress note for the patient, which the doctor would review over, edit if necessary, give me feedback, and sign. It was a good experience because I often felt more like a doctor than a student. In contrast in the UK, all my interactions with psych patients were purely for practice and happened after the ward rounds were finished (this is for Psych only — the other rotations at Blackburn you do participate in the patients care more directly). So after 6 weeks in the UK and 4 weeks in the US for psychiatry, I’d say that I had a good student-learning experience in the UK but a good student-work experience in the US.

Patient Services

One of the differences that struck me are the services that the patients are provided. In Blackburn, once a patient is emotionally safe and stable enough, they may be granted temporary leave  from the hospital to visit family, to get a smoke break, to take a walk or get some fresh air, or for any other various reasons. The leaves may be escorted or unescorted, and may range from a few minutes to a few days, depending on the patient’s progress and purpose. In the psych ward at Blackburn, there is also a patient gym with weights and treadmills which the patients may go to. The doctors at Blackburn often grant gym leave to schizophrenic patients who are experiencing weight gain from taking anti-psychotic drugs like olanzapine. Gym access helps them get active, improves their health, gives them something to do, and overall improves their psychiatric well-being. There is also a recreational facility at the psych ward in Blackburn called “Open Doors” which the patients may go to. At Open Doors, there is a pool table, ping pong table, couches, TV’s, and a kitchen where patients can cook food and get back into their normal daily lives. It’s a great place for patients to socialize with each other, contributing to the therapeutic environment of the psych ward. Having facilities like this also encourage the patient to want to improve, so that they may be granted permission to go to Open Doors. In addition, there is also a little convenience store at the psych ward where some patients can even help out at and get the work experience they need before going back out into the real world. I think all of these facilities and services at the psych ward in Blackburn make it a great place for patients to heal, improve, and get back on their feet. It gave me a view of the complex nature of psychiatric conditions, and the complex therapeutic interventions and services needed to help patients return to society.

In Miami, on the other hand, I do not recall seeing any patients granted leave from the hospital to visit family, or go to a hospital-based gym or recreation room (like Open Doors). I don’t think there was any. There are, however, smoke breaks 4 times a day, in which the patients are escorted to an area safe to do so, as well as group therapy led by social workers every day.

As I had mentioned in previous blog posts, the psychiatrists in the UK also do home visits.  Home visits help reserve the psychiatric hospital beds for those who really need it, and not to mention, the home environment may be more therapeutic for some patients. Patients discharged from the hospital are also provided doctors, social workers, or other care coordinators to follow up on them at home every other day or so, to make sure they are adjusting well at home and are compliant with their medications, give them support, and to simply say hello. I found the home visits during my time in the UK to be very interesting because it gave me a glimpse into the home setting and social situation that the patient was coming from, and it’s a dimension of the patient that is not often seen from the hospital setting. It really let me understand the patients’ conditions and how an entire team works together to treat patients. It still amazes me today that all of these services are free in the UK. In the US, I don’t recall seeing any type of service like this.

Conclusion

So in conclusion, the med student experience in the US and the UK can be very different due to the different systems’ approaches to patient care. Over these past few months, I really appreciate the opportunity to have experienced psychiatry in both the US and the UK, and it gave me an insight on the strengths and weaknesses of the different systems. But whichever system we end up practicing in, the most important thing is to do what’s safest and most effective for our patients. And as students, whichever place one chooses to do clinical rotations, the most important thing to know is if you’re proactive and eager to learn and ask questions, you’ll learn no matter where you go. Best of luck everyone!

The Health District in Miami

Hi everyone! I have just completed my first two weeks of my internal medicine rotation, with ten more weeks to go, and already, I’ve seen quite some interesting cases. I had the opportunity to see patients with enterocutaneous fistula, respiratory failure, COPD, crush injuries, hematemesis, among many. As my current attending is also in charge of the hyperbaric chambers here at the hospital, I saw and learned about hyperbaric medicine as well. The field of internal medicine is extremely broad and there’s quite a lot to see, look up, ask, and learn. The vast amount of knowledge that is required to master this field is definitely challenging, and as my attending says, “one must learn how to crawl, walk, then run.” I am definitely still learning how to crawl at this point. Nevertheless I’m enjoying it, and taking advantage of this opportunity in the hospital to learn.

For those of you interested, I’ve put together some information about the Internal Medicine rotation for AUC here in Miami.

How is the Internal Medicine rotation in Miami organised?
Internal Medicine core rotation is 12 weeks (or three months) total. In Miami, you rotate with a different attending physician every two weeks. They schedule you to have one month of inpatient experience, one month of outpatient, and one month that is a toss up between the two of your choice. Rotations are every weekday. In addition to rotations, we also have mandatory lectures once a week, as well as mandatory ER shifts 3 times a month.

Who do you rotate with?
Unlike many other teaching hospitals in the US where students may work under residents and hardly see their attending physicians, here in Miami, students directly rotate with their attending physicians. While other hospitals may assign as many as 10 students per attending, here in Miami, we rotate at most with only one or two other AUC students. Because of this low student-to-faculty ratio, I feel we get a lot more personalized attention and have a closer working relationship with the doctors here than many other places.

What is an ER Shift?
In addition to our normal internal medicine rotations with our attending physicians, MBCHC also assigns us mandatory Emergency Room Shifts three times a month. These can happen any day of the week (including weekends), and the shifts are often 10-12 hours long. If our ER shift happens to conflict with our regular rotation schedule or lecture, then our ER shift takes precedence and we attend our ER shift. We do not have to make up for the regular rotation or lecture that we missed because of our ER shift. The ER shifts are really exciting and you see all sorts of acute cases, and it takes place at Hialeah Hospital, in the emergency department. Wear your scrubs, white coat, and stethoscope.

What are the mandatory weekly lectures like?
The lectures take place every Wednesday evening (6-7pm for us), and they are mandatory. These lectures cover a variety of medical topics that are part of the clinical syllabus for AUC. The lectures are attended by both students from AUC and Ross University who are rotating in Internal Medicine in Miami. The lectures are given by a variety of doctors, and are usually very interactive, with the lecturers provoking discussion among the students. The lectures are accompanied by case studies and readings that are posted online on MBCHC’s learning media platform website. Students are encouraged to participate (and they do participate) in the online discussion of the cases. If you want to get a letter of recommendation from the program director, one of the things he may look at is how much you contribute to the online discussion of the cases. It’s beneficial to both your education and reputation to actively participate.

Are there any assignments that we turn in?
We are required to write a SOAP note every week during our rotation. Each attending you rotate with may have their own particular way to do a SOAP note. In that case, follow the format that they prefer, and write it on a patient that you saw. Have your attending sign the SOAP note and hand it into the MBCHC Internal Medicine Rotation Coordinator. Make sure to omit or mark out any names, or other sources of identity that may violate HIPAA’s patient confidentiality guidelines. Like all other rotations at AUC, you will also be required to document your cases on AUC’s case logs sheet, at least one or two for each day of your rotation. Have your attending sign your case logs, and email or mail the document to AUC’s clinical office at the end of your rotation. In addition, each attending physician may have you do presentations, reports, or other assignments.

How are we graded?
Besides the SOAP notes and case logs that you turn in, you will also need to give your attending an evaluation form from AUC in which he or she will evaluate your performance during your rotation. Since in internal medicine rotation you rotate with a different doctor every two weeks, you will have rotated with 6 doctors by the end of your 12 week rotation, along with the doctors from your ER shifts. You are required to get evaluations from at least three of these doctors (and at most 5). One of the evaluations must be from an in-patient doctor, one must be from an out-patient doctor, and one must be from your ER shift. Your final evaluation is then calculated from averaging these individual evaluations. In addition to the evaluation, you must also pass the NBME Internal Medicine shelf exam. Most people usually take the exam on the last Friday of the rotation. You can schedule the exam via the AUC Office of Clinical Student Affairs (OCSA).

What is the dress code?
For guys, nice pants, button-up shirt, tie, nice shoes, white coat. For girls, business professional + white coat. No scrubs. They prefer us to wear a blank white coat with no logo, although they will not stop you if you wear your AUC white coat. Just make sure the white coat is a SHORT white coat! You will also be required to wear the ID of the hospital you are rotating that day, and then return your ID when you are finished with the rotation.

What else should I bring on rotations?
As you’ll be examining a lot of patients, I’d recommend carrying your own stethoscope (which is required) and pen light with you. I’d also suggest carrying a pen and notepad for you to take notes on the patients you’ve seen, as well as some sort of reference book in case you need to look up something. The most popular pocket manual I’ve seen students carry is either The Massachusetts General Hospital Handbook of Internal Medicine or Oxford American Handbook of Clinical Medicine. I’d recommend the Oxford one because it’s easier to navigate through. Another book that may be helpful is Tarascon Pocket Pharmacopoeia 2012, which is a great reference if you want to look up drugs.

If you wear a white coat with lots of pockets, you should be able to fit all of these items in your pockets. If you don’t want to carry around all this stuff and you have an iPhone, you could always just download pocket manuals and drug reference guides onto your phone instead of carrying around physical books. If you have an iPhone, you can also download a flashlight app and use that instead of a penlight when examining the patients pupillary reflexes.

Which hospitals do we rotate in?
Although our school’s affiliation is with Miami Beach Community Health Center (MBCHC), students actually may rotate with any one of MBCHC’s affiliated hospitals and clinics. Therefore, students here may rotate at MBCHC, Mt. Sinai Hospital, University of Miami Hospital (UMH), Jackson Memorial Hospital, or outpatient clinics of doctors affiliated with MBCHC. Because hospitals like Mt. Sinai, UMH, and Jackson are large teaching hospitals, we get to see quite a variety of interesting cases.

When would I know which hospital and attending physician I will be rotating with?
You will usually receive an email a few weeks before your rotation starts, telling you the time and place of the orientation for your IM rotation. This orientation takes place on the first official day of your rotation, and it is here where you will take a picture for your ID, review and sign some paperwork, and receive your schedule for your IM rotation, including the hospital and physician you will be rotating with and their contact information. They will also give you directions on when and where to meet your attending for the first time. However, I would highly suggest calling your attending just to confirm with them personally, not to mention to be friendly and to simply say hi.   The orientation usually takes place at MBCHC’s office in North Miami.

Will I need to know Spanish?
While knowing Spanish is not required, I personally would highly recommend that you learn some before you come. Miami is unique in being one of the few major cities in the United States in which English is actually the minority. Spanish rules here. Practically everyone here uses it on the street as well as in the workplace, and this is true in the hospitals as well. The majority of patients you will see will be Spanish speakers, and most doctors, even those where Spanish is not their native language, will actually also know how to speak the language. If you don’t understand, they may be nice enough to conduct the interviews in English or at least translate for you. However, that may not happen every time, and it will help you if you at least know the basics to know roughly what’s going on. For Spanish learners like me, this rotation in Miami has actually been an amazing opportunity for me to get immersed in the language and improve my skills. I’d say about 80% of the patients I’ve seen so far are Spanish speakers. It will definitely put me at an advantage in the future when Spanish will become increasingly important in this country, and our society will need more doctors who know Spanish.

What textbooks do I need?
While there are no required textbooks, many students have said that Step-Up to Medicine is a great review book to get. For a review book, it’s actually quite detailed, but it nevertheless prepares you well for the NBME shelf for internal medicine as well as the Step II.

Before coming to medical school, and even during Basic Sciences, I would not have even considered a field like psychiatry. But after experiencing working with patients in the ward for 10 weeks, I was quite surprised that I actually enjoyed it, and found it satisfying, and I wondered to myself why. Is it because I newly discovered how much behavior fascinates me? Is it because each patient has a unique story to tell and presents with a different challenge to solve? Will I feel the same way with all the other specialties that I rotate in? While our interests in certain topics may change, as it often does in life, some things will never change for me. I will always be interested in people, and love caring for people long term. I will always enjoy guiding others, and feel gratitude and honored in being a part of people’s lives. And for this reason, I will have to find a specialty that will not just satisfy my interest, but complement my nature.

While reading through some blogs of AUC grads, I came across a test created by University of Virginia School of Medicine that attempts to suggest which specialties of medicine you have the most aptitude for. The test makes you fill out a questionaire of 130 questions, and calculates based on personality and preferences which specialties in medicine would be most fit for you. I was skeptical about this test at first, but after seeing the results, I gotta admit, it is actually quite accurate, at least for me. Fields like family practice, psychiatry, pediatrics, and preventative medicine all really appeal to me, and all of them are ranked within the top ten in my test results (see chart below). Other specialties like surgery, orthopedics, Ob/Gyn are fields I think may be interesting but cannot foresee myself doing them for the rest of my life, and they happen to show up at the bottom of the list. However, I am surprised to see dermatology high on this list, as I’d imagine I might find it a little boring just looking at skin all day, and as for physical med and rehabilitation (PM&R), it’s something I’ve never thought about but perhaps I could look more into what it’s all about, and why they say I may be more fitting for it.

But no matter what any matchmaking calculator may tell me, what’s most important is finding out for myself a field that I would truly enjoy doing and feel fulfilled as a person doing it. We only have one life to live, and we’ll have to live it doing what we love. And now, as a clinical student, it is my job not only to put effort in the field I think I might want to pursue, but to be open and put effort in every field I come across, so that I have utmost understanding of what’s best for my future.

Here are my results! If you’re interested in seeing what specialty you may be fit for, please check out UVA’s Medical Specialty Aptitude Test here.

Rank	Specialty	Score
1	pediatrics	48
2	family practice	48
3	med oncology	47
4	dermatology	46
5	physical med & rehabilitation	46
6	psychiatry	46
7	general internal med	45
8	rheumatology	45
9	preventive med	44
10	occupational med	44
11	radiology	43
12	radiation oncology	43
13	nephrology	42
14	hematology	42
15	allergy & immunology	41
16	anesthesiology	40
17	endocrinology	40
18	pathology	40
19	colon & rectal surgery	39
20	gastroenterology	39
21	infectious disease	38
22	neurology	38
23	neurosurgery	37
24	aerospace med	37
25	nuclear med	37
26	pulmonology	37
27	emergency med	37
28	plastic surgery	36
29	thoracic surgery	35
30	obstetrics/gynecology	35
31	ophthalmology	34
32	cardiology	34
33	orthopaedic surgery	33
34	otolaryngology	31
35	urology	31
36	general surgery	30

Standing in the hall with my eyes closed, I could sense her walking towards me from behind. She gently laid her hands on my shoulder. I turned around and opened my eyes. There she was, my bride, and she was beautiful.

This past week had been one of the most amazing weeks in my life – Irene and I finally professed our love for one another in front of our dearest friends and family, said our vows to each other, and officially gotten the blessings from our parents during an intimate Chinese Tea Ceremony.

We feel so thrilled to be able to celebrate with all our loved ones. It’s not everyday that that so many of our friends and family are together in one place, so it was really good seeing everyone. Most of our guests had traveled far to come to Miami for our wedding, some even traveling from overseas. I got to catch up with my college roommate of 4 years, Carl, who I hadn’t seen since we graduated from Washington University in St. Louis nearly 7 years ago, as well as my aunt Jeko and her husband Hank from California who I hadn’t seen since I was a scrawny little kid in high school. I saw my cousins and relatives from across the country, as well as second cousins from Taiwan. I saw long-time family friends and my best friends from AUC. I met a lot of people important in Irene’s life. It was an honor and a pleasure to have shared our special moment with everyone that night. Thank you so much everyone for being there with us. You made it a magical night for us.

Special thanks goes to our parents for raising us to become the individuals we are today and for hosting our event, our long-time family friend Mr. Okuma for leading our ceremony, our friend Vicente Lai for his violin playing, Jimmy and April Ho for the photobooth, guestbook, and everything else you’ve done for us, our bridesmaids, groomsmen, and parents for the awesome speeches and skit, Ana and Lester for the decorations, Tresha Titus for the planning of this most amazing night, Nikki Kidd band for the beautiful music and spirit to get the crowd moving, and the one and only Jim Colman for his amazing work behind the camera!

Cost-U-Less in Philipsburg, St. Maarten

Cost-U-Less

Similar to: Wal-Mart

Best Deals: Bathroom supplies, laundry stuff, kitchenware, feminine products, random things, food in bulk, school supplies, plastic kitchen things

Dining:

• 200 plastic cups: $15
• 100 paper plates: $5
• 15 standard tupperwear containers: $8
• 36 piece tupperwear set: $17
• 300 plastic spoons: $7
• 300 plastic forks: $7
• 36 real forks: $13
• 36 real spoons: $11
• Cookware Set: $60-$70 ***AUC STUDENT FAVORITE***

Laundry Essentials:

• Laundry detergent: $20
• Fabric softner: $15
• 120 Dryer Sheets: $8
• Febreeze: $5

Random:

• Twin Air Mattress: $43
• Queen Air Mattress: $57
• Beach Chairs: $25-$60
• Bug Spray: $7
• Raid: $8
• Standard Folding Table: $50
• Ironing Board: $38
• Queen Sheets: $23-$35
• Twin Sheets: $28-$35
• 3 pack of plain white towels: $22
• 3 pack of plain white hand towels: $14
• Sponges 4 pack: $5
• Swiffer Sweeper Starter Kit: $10
• Swiffer Sweeper Refills 32 pack: $9
• Energizer AAA – 4 for $5
• Store Brand AAA – 24 for $12
• Duracel AAA – 20 for $12
• Energizer AA – 4 for $5
• Store Brand AA – 24 for $12

School Supplies:

• Giant Dry Erase Board: $23 ***AUC STUDENT FAVORITE***
• Expo Markers Combo Pack 16 markers: $16 ***AUC STUDENT FAVORITE***
• 15 Multicolored G2 pens: $17
• 15 Blue, Black, Red G2 pens: $17
• Cannon Pixma Inkjet ip2702: $45
• Roll of Tape: $2
• Notebooks: $2
• Computer Paper: $10

Bathroom Items:

• Big box of Q-Tips: $9
• TreSemme Shampoo 32 ounce: $6
• TreSemme Conditionor 32 ounce: $6
• Big bottle of Olay lotion: $13
• Body Wash: $6-$9
• Axe Deodorant 2 pack: $10
• St. Ives face wash: $4
• Secret/Lady Speed Stick/Dove Deodorant 2 pack: $5-$7
• Bathroom spray: $2
• Toiler Paper 12 rolls: $10
• Toothbrush 4 Pack: $6
• Toothpaste: $3-$5
• Listerine: $9

Feminine Products:

• 120 Care-Free pads: $7
• Kotex 135 count: $6
• 40 count multipack Tampax: $8
• 36 count Pearl Tampax: $10
• 48 count Maxi Pads: $8
• 28 ultra thin pads: $9

***Tampons boxes other than “regular” are harder to find***

ACE Hardware Store

Similar to: Lowe’s / Bed,Bath & Beyond

Best Deals: Bedroom things, kitchen machinery, apartment decorations, things for your car, cleaning supplies, fix-it-up things, real kitchen things, greater & cheaper selection of cleaning materials (Clorox, wipes, etc.)

Bedroom:

• Queen Mattress Pad: $125 ***AUC STUDENT FAVORITE***
• Full Mattress Pad: $50
• Queen Egg Crate Mattress Pad: $125
• Twin Egg Crate Mattress Pad: $25
• Big Pillow: $25
• Regular Pillow: $10-$15
• King Sheets: $40-$60
• Queen Sheets: $35-$40
• Full Sheets: $25-$35
• Twin Sheets: $12-$15
• King Comforter: $180-$200
• Queen Comforter: $120
• Twin/Full Comforter: $80

Kitchen Machinery:

• Coffee Maker: $35-$60
• Toaster: $20
• Blender: $37-$80
• Can Opener: $16
• Knives: $6-$50
• Disk Rack: $12-$15
• Pasta Strainer: $12-$15
• Real Plates: $7-$10
• Real Cups: $6-$12
• Baking Pan: $10
• Toaster Oven: $70

Random:

• ZipLock Baggies: $5
• Plastic Laundry Basket: $20
• Shower Curtain: $5-$15
• Shower Curtain Hooks Pack: $3
• Bathroom Shower Mat: $15
• Bathroom Rugs: $27
• Trash Bin: $10-$40
• Hand Towels: $7
• Towels: $15
• Welcome Door Mat: $16
• Small Beach Cooler: $25
• Lunch Pail: $11
• Lawn Chair: $40
• Broom: $6-$13
• Toilet Brush: $6

Things to bring from home

• Starter Medicine Kit: Ibuprofin, Aspirin, Niquil, DayQuil, bandaids, birth control, any regular medications you take, etc. “Drug Stores” don’t exist here. You have to buy all of this at the pharmacy, which is not open on Sundays, and the hours open are during class. Better to be safe than sorry.
• Starter Bathroom Kit: small shampoo, box of tampons/pads, loofa, toothbrush, toothpaste, one role of toiler paper, shower curtains, shower curtain hooks, and towel just in case your plane arrives at night when everything is closed
• Starter Bedroom Kit: surge protector, sheets (they are more expensive here), a nicer pillow (no memory foam here)
• Kitchen Starter Kit: any favorite spices, they are very expensive here and limited
• Starter School Supplies: nicer folders, special pens, post-its, tabs, etc. bring from home if you are picky about your school supplies!!

For cost of groceries, please check out this post: How Much Do Things Cost in SXM?

London Eye

There’s no doubt that coming to the UK for rotations is a unique experience, not only because of the well-known clinical learning opportunities of the UK teaching hospitals, but also because of the many great travel opportunities here as well. While my six weeks in the UK was shorter than how long most AUC students who come here stay, I managed to take advantage of both the learning and travel opportunities to the fullest extent, and looking back, the experience was truly enriching.

During my stay in the UK, I dedicated my weekdays to my psych rotation, clerking and writing up patients, doing practice questions, and studying the topics that my attending physician suggested that I study. As my rotations were my priority, I did not take any days off, and got all my studying done before the weekends arrived. Because 6 weeks is a short time and I did not know when the next time I’d return to the UK would be, I managed to dedicate every one of my six weekends in the UK towards exploring the country, exploring six different regions in the UK.

Benji’s 5 Tips on Traveling in the UK:

1. Get Familiar with National Rail! – The best way to get around the UK is by train and bus. Before traveling anywhere in the UK, the first place you must go is National Rail Enquiries. This site gives you all the train schedules in the UK, and tells you exactly which platform at what time you have to catch the train, as well as which stations you must transfer, if necessary. Before going on a trip, I usually take pictures of the train schedules that I may take to and from the destination. That way I have a better idea as to when I should plan to arrive or depart each location I am going to, as well as get a better estimate as to how long I should stay at each location.

2. Enjoy the Train Ride! — The train ride isn’t just a way to get to an attraction, the ride itself is already an attraction! Some of the most beautiful scenery you’ll see will be on trains, going through the pastoral British countryside. Likewise, enjoy any bus or plane trip you may take.

3. Stay at the Hostel! – As students, we’re always looking at ways to save money. While staying at a hostel might be everyone’s “thing,” hostels are definitely a great place to meet other like-minded travelers, and if you are traveling alone, this is especially great since you may meet a temporary travel buddy who you can go with together. A lot of the hostels in the UK are actually pretty nice, and you can save a lot of money by staying in them.

4. Buy round trip tickets! – A round trip ticket is will cost usually only a few pounds more than a one-way ticket, so always purchse a return ticket! Once you buy a ticket, you can take any of the scheduled trains that will reach your destination, so you don’t always have to plan beforehand when exactly you want to leave or come back. If you had originally planned to take a certain train back and decided you wanted to stay longer and explore a place more, you could always just catch the next train, using the same ticket! Also, if you wanted to make multiple stops along the way to your final destination, you can do that as well with your ticket.

5. Engage Your Senses! — Traveling is more than just going to a place and checking it off on your checklist. No, to travel is to engage your senses in a new place. You don’t really know how tall a mountain is until you climb it. You don’t really know what the people are like until you talk to them. And with food, try something new. You may discover something that you like or at least appreciate why others like it.

Videos From My Trip!

Manchester

York

Scotland

Eastbourne

London

Chester

Wales

Lake District

That morning, we had two patients lined up to do ECT.  Our first patient walked in for his monthly ECT appointment. He spoke normally, was well kempt, and seemed like any other person you’d meet. With the help of an anesthesiologist (or anaesthetist, as they call here in Britain), he was first given propofol (a short-lasting general anaesthetic, although thiopental is generally used more since propofol may decrease ECT activity) and suxamethonium (a muscle relaxant). The patient immediately fell asleep and became completely relaxed. As the diaphragm muscle was also relaxed, the patient was given artificial ventilation to help him breathe. A mouth guard was put in place to prevent the patient from biting the tongue. EEGs were attached to his forehead to monitor his brain waves. It was then that the junior doctor put two electrodes on the temporal sides of the patient’s head, along with a lubricant that eased the conduction. With the dosage set on the machine, the nurse activated the ECT, and suddenly an electric shock flowed through the patient’s head for a few seconds. The patient’s entire body immediately tensed at the activation of the electrodes, and for the next few seconds, convulsed, then relaxed. Not long after, the EEG printed out to show the duration of the convulsion. While visually we only saw the convulsion for less than 10 seconds, the brain scan shows it actually lasted around 40 seconds in the brain… “that was a good seizure” proclaimed the senior doctor. “Ideally you’d want at least 25 seconds.” The procedure was over.

The patient, now completely relaxed and still asleep, was wheeled into the recovery room by the nursing staff.  A few minutes later, the patient opened his eyes. He felt a bit drowsy but was in no pain. As protocols, the nurse asked him a few questions to test his memory and cognitive performance. “Do you know where you are?” asked the nurse. For a brief moment, confused, the patient had no recollection as to what had happened. “You just had a session of ECT.” The patient eventually started remembering, and within 15 minutes, his mind was back to normal, and up on his feet. The nurse offered him some tea with milk, as is customary in Britain. He graciously accepted. I asked him how he was feeling and he told me he was feeling better. The patient then told the medical team that he was very satisfied by the improvements in his well-being from the treatment and wishes to continue treatment.

Seeing this patient today and how normal and well of a life he leads today, it’s hard to imagine that at one point in his life, this patient was once extremely depressed, with multiple suicide attempts, hallucinations, and delusions that severely handicapped his ability to function in society. Antidepressants were not working well enough for him, and he could not afford to wait longer for the drugs to kick in, which often takes several weeks if not months to see effects. Each day that passes was a risk of death by suicide for him. He was a good candidate for ECT. Unlike antipsychotic drugs, you can see much faster and more immediate results with ECT, and studies have shown that ECT often works just as well, if not better, than medications. Within just the first few doses, it was already clear that this patient was improving. Today he is living a more or less normal life with his wife and family and only comes in once a month for a maintenance dose. For him, the ECT treatment was routine, and it was what kept him alive to this day, functioning, and well.

So despite the bad image that ECT often gets in public, I realized during my time on the ECT unit that ECT today is actually a life-saving procedure that is very effective, and its adverse effects of short-term memory loss and disorientation are really just temporary, and are easily recovered. The procedure is short and quite humane, with the patient not being aware during the procedure. Treatment planning in psychiatry is all about risk assessment and what’s best for the patient’s given situation, and often times ECT may be the last hope to improving a patient’s mental well-being.

A Little History of ECT

ECT originally started in the 1930s when doctors at the time noticed that people who have a history of epilepsy seem to be less likely to have psychosis (although this was later discovered to not be entirely true either). Applying this observation, a neurologist by the name of Dr. Ugo Cerletti in 1938 decided to artificially induce a seizure in a patient with severe psychosis, by using electricity. After a few sessions of shock, Cerletti was able to bring the patient back to a functional state of mind. ECT was born.

Why is ECT used?

Studies have shown that ECT is just as effective, if not more effective, than pharmacological interventions in the treatment of depressed patients. So why would you use ECT over drugs? Well, drugs for depression often take many weeks to kick in, whereas the patients who undergo ECT often see results as early as the first dose, and even better results after second and third. Because of this, ECT is mainly reserved for people who either do not respond well to drugs, or who are severely depressed and psychotic who need to get better immediately. These patients are often the ones who are on the brink of suicide, neglect, or danger, and cannot afford to wait 5-6 weeks for drugs to kick in.

How does ECT work?

From what I understand, no one really knows for sure yet. They like to say it “reboots” the brain, but exactly what does this mean?

How is ECT administered?

Often patients are given a course of ECT anywhere from 6-12 sessions, twice a week in the UK (or 3 times a week in the US). The doctor may start the patient off with perhaps a 5% or 10% dose, and work up as needed. 200% is the highest dose one can get. ECT can be given unilaterally or bilaterally. If you are doing unilateral ECT, you need to increase the dose by 4 times.

Giving ECT unilateral on the non-dominant side of the brain has less side effects on memory loss than on giving ECT bilaterally. Therefore unilateral is often used more with older patients, who cannot suffer from any more memory loss. Since the maximum dose for ECT is 200, however, and unilateral is equivalent to 4 times bilateral dosage, the maximum dosage for unilateral ECT is only 50, which may not be enough for some patients.

What are the side effects?

The biggest side effect is temporary short-term memory loss. When the patient first gets finished with ECT, he/she may be disoriented to time and place, but they usually become oriented again after 15 minutes or so. There is also retrograde amnesia, in which the patient may forget the events leading up to the ECT. Sometimes, there may also be anterograde amnesia in which they do not remember the events after ECT later on. Despite these memory problems, there hasn’t been any sufficient evidence of permanent hindering of learning, cognitive, or memory ability, and nor is there evidence of ECT changing brain structure. Nevertheless, further research and analysis should be done to continue to improve its use. ECT has come a long way since it was developed in the 1930s, and certainly much more humane today than how it was practiced before the development of anesthesia. ECT as it is practiced today is generally considered safe and effective by the medical community, and has made a come back in recent years despite a negative image in the media.

1. Somatization
2. Self Harm
3. Psychosis
4. Mania
5. Depression
6. Anxiety

Psych Ward at Royal Blackburn Hospital

It’s amazing how fast my rotation has gone by.  Now, with less than a week and a half left, I feel the more I learn about Psych, the more I feel there is to learn. The actual practice of psych is so much more than what we learned in Behavioral Science, ICM, or Pharm, and 6 weeks of rotation cannot do it justice. The knowledge and experience that these doctors have amazes me.

There are some thoughts I’ve had during this rotation:

Back At The Bottom

On the island, as we progressed through the semesters, and eventually reach fifth semester, we feel like we’ve reached the top of the pecking order at school, having more knowledge and more experience than anyone else in other semesters below. Once you start clinicals, however, you again start at the very bottom. Now I realize that all the facts and details that we learned in class that we thought made us sound smart is common knowledge at the hospital, and it’s humbling to feel that as a new clinical student I probably know the least compared to everyone else on the health care team.

Know Your Stuff

The classes one uses the most in Psych are by far Pharm (especially Psych section in Pharm II), Behavioral Science, and ICM, particularly the interviewing part. Medical Ethics is used to an extent as well, especially when you assess whether or not a patient has capacity, and whether or not he/she should be detained involuntarily. Every interview here on the Psych ward is basically an Advanced Interview we do for ICM 4 and 5. The way they taught us to do the psych interview and mental status exam in Behavioral Science I, even the order, is the way they practice it here in the hospital. Know everything that you were taught in these three classes well. Some stuff you learned in Behavioral Science you may feel is less relevant to the actual practice of Psych, like Piaget’s Theory of Cognitive Development (and it probably is), but I got pimped on this on the ward. So for those of you still in Basic Sciences, know your stuff, even when you don’t quite understand why you should know it… you may realize why later on.

Severity

Being in the Psych ward and seeing how these illnesses affect people and their families, I’ve come to realize that Psychiatric disorders are among saddest types of disorder out there. It can severely deteriorate the patient’s quality of life, handicap the patient, and even cut the patient’s life short, just like any other medical condition. It also tremendously affects the family and loved ones of the patient. Can you imagine worrying constantly whether or not you’ll come home to find your loved one overdosed or hanged? Or whether or not you’ll be able to walk out of the house with your wife again, who has become too anxious to go outside? Or a spouse who suddenly spends all the money that you earned because he/she was on a manic episode? I’m not just making these scenarios up… these are real cases I’ve encountered here at the ward, and on the home visits I’ve gone with my attendings.

Often those who suffer from psychiatric illnesses also further suffer from the stigma associated with them in society, especially when looking for a job after their discharge, jobs that could bring back happiness and meaning to their lives. Often times giving a psychiatric explanation for an illness is last resort, because of the stigma of labeling someone with a psychiatric diagnosis.

Real Medicine

In Basic Sciences, I’ve often heard students say that they’re not interested in going into Psychiatry because “it isn’t really medicine.” Being here, you realize that yes, psychiatry may be different from other specialties of medicine, but the problems patients face are real, and often very severe too, that are often not self-limiting, and require intensive medical interventions. It’s not easy to treat patients sometimes and relapse is common. Extracting information from the patient, determining a diagnosis, and planning the patient’s treatment all involve the artistry and skill of the doctor, and in these aspects, psych is no different from any other field of medicine. I’ve gained a lot of respect for psychiatrists during the rotation.

Giving Hope

At first, I felt emotionally drained from hearing all the sad stories that happen to patients. Just when you think a person’s history can’t get any worse, you soon realize that it gets worse. I’ve seen patients who have gone through abuse, rape, attempted suicide, self-harm, neglect as a child, drug dependence, or witnessed loved ones commit suicide. I see patients who hear voices or see things that they do not want to see and will even resort to harming themselves to get rid of them. The psych ward may seem like a sad place at first… with some patients closely monitored every 10 minutes, while others may spend most of their day sitting in solitude in a chair, staring into space. However, to many of these patients (particularly those with insight), this environment of the psych ward is actually very therapeutic. It is a safe place, often safer than where they come from. Their schedules are controlled, and there are others around them who may have gone through the same experiences as they have. The practice of psychiatry gives them hope, and it’s fulfilling to see some of these patients get better, eventually getting discharged, and working together with the mental health team to lay out long-term care plans, living arrangements, and follow-ups, in hopes of a brighter future.

Sim Man

Earlier this week, two of my AUC colleagues and I had an awesome Sim Man learning session together with Dr. Butler. This is the first of two Sim Man sessions that I am required to attend for my rotation at the Royal Blackburn Hospital. I thought the session was very helpful and Dr. Butler did a great job preparing the four different scenarios we saw of varying severity. Compared with my first Sim Man experience on the island, I thought my team and I were much more confident this time in taking immediate action and working together to stabilize our patient, ordering the relevant blood tests, and determining the cause of the emergency.