Royal Blackburn Hospital

Hi everyone! I’d like to talk more about my schedule for my Psych Rotation here at Royal Blackburn Hospital in Blackburn, England.

I go on my rotations five days a week from Monday to Friday. Each morning from around 9:30am to 12pm, I attend ward rounds in which the consultant doctor, nurse, social worker and other members of the health care team reviews and assesses a select number of patients seen that morning, on average around 4 patients per morning. The assessment may be for any reason: A new patient who needs to be assessed and have a full history taken, a patient who is doing well and is going through discharge planning, or simply a patient who needs a routine review. For each patient, the health care team will usually read the patient’s history, update the doctor on recent encounters with the patient, and then the team will discuss what they want to discuss with the patient, what to tell the patient, and what approach to take to talk with the patient. The patient will then come in to the interview room where the doctor will talk with the patient and find out how the patient is doing with the current treatments, and inform them of any treatment plan changes.

From 12pm to 1pm, I usually go eat lunch at the cafeteria in the hospital. It’s only a few steps away from the Psych Ward, so it’s very convenient to go to. The food is ok, as good as hospital food can get, but it’s convenient and fills the stomach, which is most important… they have a salad bar, hot foods, sandwiches, as well as prepared snacks and desserts.

At 1pm I usually return to the ward, and talk to patients, take full histories and conduct mental status examinations. I would then meet with one of the ward doctors and present the history, and he/she will give me feedback, teach me different topics, and give me some material to read up on. I usually come home around 4pm, but they won’t stop you if you want to stay longer, or come back earlier to study.

Every Wednesday afternoons at 1pm, I go to Teaching Sessions given to Junior Doctors at the hospital. As it is located at Royal Blackburn Hospital’s sister hospital, Burnley Hospital, in Burnley, the next town over, I take a half-hour free bus ride there. During the teaching session, there is usually a unique case presented by a junior doctor and discussed, as well as a journal club in which a junior doctor presents research studies pertaining to the practice of Psychiatry. Sometimes, there may also be workshops that teach certain skills for Psychiatrists.

The AUC Clinical Leads at Royal Blackburn Hospital (Dr. Sibley and Dr. Coutts) do their best to have a unique curriculum for AUC students that differs from the curriculum for the University of Manchester medical students who also rotate at the hospital. Every Thursday afternoons at 1pm, I go to Problem-based Learning (PBL) Sessions. These sessions are held exclusively for us AUC students, and we are all required to attend it, even though we may be rotating in different specialties. During the PBL session, Dr. Sibley and/or Dr. Coutts usually goes over a typical Step II-style case and we discuss how we should approach the case, what we should think of, what our differentials should be, and how to test for them or treat them. We would also go over cases that we’ve seen ourselves so far in our rotations and discuss it in the group.

In addition, the AUC program at Blackburn has set up two Sim Man sessions exclusively for the six of us AUC students who are there right now. They have also set up a morning visit to the Children’s Hospice for us, which I will go to next week with a group of my AUC colleagues. Currently they are also working out a few additional skills workshops for us that are optional.

My attending Dr. Adelekan suggested that I take as much advantage as I can of the invaluable opportunity I have here at the hospital to see real patients as this is the only chance we have during med school in learning the tricks of the trade in the real-world setting.  I agree with him and I’ve been taking his advice.

]]> http://www.caribbeanmedstudent.com/2012/02/my-psych-schedule-at-blackburn/feed/ 3 http://www.caribbeanmedstudent.com/2012/01/weekend-in-scotland/ http://www.caribbeanmedstudent.com/2012/01/weekend-in-scotland/#comments Tue, 31 Jan 2012 21:10:55 +0000 Benji http://www.caribbeanmedstudent.com/?p=6083 Continue reading Weekend in Scotland

Coming abroad to the UK for clinical studies, it’s difficult not to take advantage of the weekends to explore the country. Being in an age-old and dynamic place as the UK, the travel opportunities are endless, and relatively easy, with the extensive train networks and public transportation here.

This past weekend, after a week of ward rounds, patient interviews, and learning sessions, I headed north from Blackburn by train to Edinburgh (pronounced “Edinburruh”), the capital of Scotland, to meet up with my friend and classmate Gundi from AUC. As Gundi was doing her clinical rotations in London, she flew up by plane, as a train would have taken her 6 hours or so. I was happy to see her again and it was nice to explore a new place with an old friend, like we did when we were on the island.

Scotland is an absolutely beautiful place with a deep history, unique culture, and a small, yet fervent populace, and worth visiting as a weekend trip if you are ever in Blackburn for clinical rotations (but first plan on getting your studying done on the weekdays, so you’ll have time to enjoy the weekend!). Check out this video I made from our trip!

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Last week I had been rotating with the Crisis Response and Home Treatment Team (CRHTT), so all of the psych patients I saw last week had been house visits. This is something you don’t really get to experience in the states. Over here in the UK, before getting sent to the wards, patients are assessed to see if they are eligible to be treated at home with their family. Some patients (not all of course) fare better when treated in an environment their comfortable with, and this can free up some hospital beds to those who really need it. This service is all paid for by the government here. I felt the home visits were a great experience because it really gave me a perspective on where these patients were coming from, and how their illnesses were affecting the people they live with. I got a glimpse at what the patients’ wives, husbands, children, parents, and siblings go through everyday, and it’s often very sad to see.

I saw a previously normal patient who developed an anxiety disorder after a certain event happened in her life. She was tremulous and would cry at everything and anything that we said to her, and she was not able to step out of the house. When we visited her at her home, her husband expressed that all he wanted is to be able to take an evening walk around the neighborhood with his wife again, like they used to. As a husband and a human being, I could relate to him, and I’d be so sad if something like this ever happened to Irene.

This week, in the inpatient psychiatric ward in the hospital, I have begun taking psych patient histories. It is very similar to the histories we learned to take in ICM, but has certain aspects geared towards Psychiatry. For each encounter we also do a Mental Status Exam, equivalent to the Physical examination in other fields in medicine, and sometimes a Mini Mental Status Examination as well to probe into the patient’s present cognitive abilities. Both of these we learned how to do in ICM and Behavioral Science, but now we actually get to do it with real patients. So far most of the patients I’ve seen here have either Schizophrenia or Depression. Some are very easy to talk to. Others, not so much. It’s the ability to extract information from patients (even from difficult ones) and interpret them and find an appropriate treatment for the situation that makes a good psychiatrist.

A good doctor would also have to be able to see through malingering, which is when a patient feigns his or her illness to get financial benefits. We had a patient who complained of suicide ideation and came to the hospital to seek help. On further examination and history taking, it was shown he had no other typical symptoms of depression, and that he came to the hospital right after he was kicked out of his friend’s house after a big argument. He did not have a home of his own and was crashing at his friend’s place. He admitted to one of the nurses that he came to the hospital because he just wanted somewhere to stay. Turns out that this patient had a history of misusing social services, and the doctors, who have years of clinical experience with real patients, could see through his malingering.

Like with all fields of medicine, a patient’s life situation is of utmost importance in Psych. Making a diagnosis or even starting a certain drug may not be something one decides lightly. I learned that sometimes even the decision as to whether or not to diagnose someone should be considered carefully, as getting labeled with a mental illness may often stigmatize a patient in his or her family, culture, or society for life, and for some may prove more harm than help. For example, if the patient is a youth, diagnosing them too hastily (or misdiagnosing them) will permanently label them, leading to difficulty in finding a job in the future. All possibilities and interventions must be considered before giving someone a diagnosis. Often times, it may be better to seek non-pharmaceutical interventions to see if the patient can improve first before labeling somebody with an illness and start on medications, which have side effects. It all depends on the patient’s specific situation, and it is the doctor’s intuition, ability to see the big picture, and plan that I am learning here in clinicals, stuff that you can’t really learn from just reading books or sitting in a classroom.

Anyway, here’s some stuff I learned about taking psychiatric histories for you to enjoy!

PSYCHIATRIC HISTORY

1. Setting the Stage
1. Make sure you’re in a safe position,
2. Introduce yourself
3. Figure out the chief complaint and all the other complaints the patient wants to talk about.
4. Set the agenda.
5. Ask for verbal consent for the interview.
2. Identifying Info
1. Get information on their sex, age, occupation, who they live with, where they live.
3. History of Present Illness
1. Ask about the circumstances that led to the hospital admission. In your head, keep asking yourself if this is abnormal.
2. For each current complaint, ask about onset, duration, severity, progress, aggravating/relieving factors. Keep in mind whether or not the patient’s complaints are qualitatively and quantitatively normal.
3. Keep in your mind a differential diagnosis, and then ask questions that would key in on a working diagnosis.
4. Ask if there are any self harm thoughts, self harm attempts. If there have been attempts, ask about the nature and degree.
5. Ask how the patient has progressed, and ask how the illness has affected the patient’s life.
4. Past Psychiatric History
1. Ask about other psych problems that the patient may have had in the past.
2. For each one, ask about symptoms, onset, severity, how it has affected the patient’s life, whether or not the patient was admitted to the hospital, and whether it was voluntary or involuntary.
3. For each episode, ask how the patient was treated (medication, therapy, care coordinator), and the results. Ask what helped and what did not help.
4. Ask if the patient had self harm or harm to others at the time.
5. Link the episodes together — is the patient getting worse? better? Patients with schizophrenia often gets worse over time, whereas patients with depression may appear normal between episodes.
5. Past Medical History
1. Ask about past medical problems and their treatments. Events like getting cancer and surgery can often lead to depression. Conditions like Cushing’s disease and hypothyroidism can also have psychiatric effects. Some viruses can even effect the brain, causing psych problems. Medical problems can have both direct and indirect consequences in behavior.
2. Ask about current medical problems and the treatments that the patient currently takes.
3. Ask about allergies, illnesses, hospitalizations, etc.
6. Family Medical History
1. Ask about the patient’s family — how many siblings? children? parents still alive? if deceased, how? divorced/separated?
2. Ask if there is anyone else in the family with mental health problems, self-harm/suicide, or alcohol/drug abuse.
3. Ask if there has been any crime in the family.
7. Personal Social Background
1. Birth — was the patient full term? preterm? natural? c-section? asphyxiation during birth? any problems during birth (i.e. placenta previa)? Was the patient’s mother’s pregnancy OK? did the mother take drugs, drink alcohol, get xray/radiation, or get a TORCH infection during pregnancy? How was the patient’s APGAR score when born? Problems during birth and fetal development can be associated with behavioral problems in the future.
2. Milestones — did the patient develop normally through childhood? how was upbringing at home? how did patient’s development compare with peers/friends?
3. School — did the patient go to a mainstream school? special school? did the patient have learning disabilities? how were peer relationships? did the patient complete school? did the patient go to college?
4. Jobs — what jobs did the patient have? what was the longest job? what was the last job and when? why did it terminate? Was there a frequent change of jobs because the patient can’d do the task? Can they cope with challenges of the job?
5. Relationships — First relationship? longest relationship? last relationship? what happened? does the patient still have feelings for the relationship? current relationships? children/dependents? children can affect relationships. Was there a frequent change in relationships?
6. Current Social Situation — how is current relationship w/ significant others or family? any friends? any stresses? any support?
7. Sexual History — don’t underestimate the importance of this.
8. Finances — can be a source of stress
9. Values/Beliefs — can affect how they think or act or see the world. Could also be a source of support. Need to differentiate between beliefs that is aligned to their culture vs. beliefs that are delusional.
10. Self-Sustainability — can patient care for him/herself? IMPORTANT TO ASK!
11. Any other significant events in the patient’s life?
8.  Substance Use History
1. Alcohol? Smoking? Drugs?
2. Amount? Frequency? Duration? Look for any addictions.
3. Effects — Physical, mental, social, forensic (i.e. has the patient been arrested for alcohol or drugs?).  Long-term cannabis use has effect on brain/behavior, especially when people are genetically predisposed to psychiatric illnesses.
4. was there an environmental stressor that started the substance use?
9. Premorbid Personality
1. Ask patient and family/friends what the patient was like before the illness. Ask what is it like now.
2. How has personality changed?
3. How does patient feel about personality now?
10. Forensics
1. Has the patient been in trouble with the law before?
11. Risk Assessment
1. Risk of harming self? Risk of harming others? Risk of getting worse?

MENTAL STATUS EXAMINATION
Gives a general observation every time you see a patient. This has the equivalency to a physical exam for Psychiatry.

1. Appearance — Eye contact? Rapport (friendly? cooperative?), abnormal movements? alert?
2. Speech — rate? variability in tone? volume? sparse speech? lots of speech? word salad?
3. Mood — Euthymic? Reactive? Congruent or Incongruent? variability in emotion?
1. Subjective — how does the patient describe his/her mood? high? low?
2. Objective/Affect — how do you see the patient’s mood as? How does the patient express his/her mood? blunted? flat? appropriate? inappropriate?
4. Thought
1. Content — delusions of grandeur? paranoia? reference? self?
2. Possession — thought withdrawal? insertion? broadcast?
3. Formal thought disorder — negative? positive?
5. Perception
1. Illusions — false interpretation of real things
2. Hallucination — sensing something that is not there. Auditory/visual/olfactory/gustatory/tactile hallucinations?
3. Are illusions/hallucinations mood congruent or incongruent? Psychosis in depression is often mood-congruent. Psychosis in schizophrenia is often mood-incongruent.
6. Cognitive — this is done more in the Mini Mental State Examination (MMSE)
1. Orientation — to person, place, time.
2. Memory — see if patient can register (ask them to repeat a phrase you say), recall (ask them to repeat something you said 5 minutes ago), remember recent events (past few days), and remote events (i.e. memories from childhood).
3. Attention/Concentration — see if patient can spell “world” backwards, but first know if he/she can spell “world” forwards correctly. You could also ask them to subtract serial 7′s from 100. They have to be able to count back 5 times. Patients with Schizophrenia often have trouble with this task.
4. Knowledge — who is the queen/president? Name three large cities in the world.
5. Reading/Writing — see if patient can read something, or write a sentence of his/her own.
6. Comprehension — point to something and ask the patient to name it. Say a series of commands and see if the patient can do it correctly.
7. Visual-spatial Thinking — ask the patient to copy a complex shape.
8. Abstract Thinking — i.e. what’s does an apple and orange have in common? patients who are capable for abstract thinking will say “they are both fruits.” Those who are not capable, like in many schizophrenia patients, may say “they are both round.”
7. Judgement — ask the patient what he/she would do if she smelled smoke in the theater.
8. Insight
1. How does patient think about his/her illness?
2. Does patient think it’s a physical or mental problem?
3. Does the patient think he/she needs treatment? Does the patient think it will help?
4. Does the patient want help?
5. Does the patient have poor, partial, or full insight?

• Zebra – This is what they call a crosswalk, which looks like zebra stripes on the road. Clever!
• Cheers – This means Thank you, as in what you say when someone holds the door for you. If “cheers” is “thank you,” then I’m not sure what they would say when they just want to bump drinks at dinner.
• City centre – This is what they call downtown.
• GP – Since I am rotating in the hospital here, I hear this term all the time, which is equivalent to Primary Care Provider (PCP) in the US. GP stands for General Practitioner.
• Pudding  – While in America you’d think of this as a corn-starchy glob-like sweet dessert, in England, it could mean either some type of pastry, or some type of moist bread, as in bread pudding or steak & kidney pudding.
• Shattered – It means “tired.”
• Pear-shaped – hay-wired, or when something that was planned goes unexpectedly wrong.
• “To Let” – “For Rent.” You see these signs everywhere here. At first I thought they just forgot to put an “I” in the word.
• Asian – not the “Asian” we typically think of in the US. In Britain, “Asian” refers to Indians and Pakistanis. They would not consider me Asian. Instead, as a Taiwanese-American, I would be considered “Oriental,” like the rug.
• Hiya – the most common greeting you’ll hear here in Blackburn.
• Operation Theatre – Operation room
• Car Park  – Parking Lot
• Car Hire – Car rental
• Rubbish – trash
• Yankee – slang that refers to all Americans, not just Americans from the northeast region. I’ve only been here a week, and I’ve already been called this twice, even though I tell people I’m originally from Georgia.
• To clerk a patient – to take the history of a patient.
• My love – very common thing they call familiar people here, not necessarily between lovers, but between friends or even coworkers who may be closer.
• Shopping Centre – They don’t call malls “malls” here. Instead they call them shopping centres. In Blackburn, they named the Shopping Centre “The Mall” as if it were a fancy name rather than a common noun.
• Pissed – Pissed does not mean “mad” here. Instead, it means “drunk” or “wasted.” Example: Pissing the night away. I get knocked down, but I get up again…
• Fortnight – 14 days. They use this term quite a lot, like “I stopped taking the medicine a fortnight ago.”
• Quid – pound, as in the currency. I guess it’s kinda like how we say “10 bucks” for “10 dollars” or “5 grand” for “5 thousand.”
• Stone – 14 pounds, especially when patients talk about their weight. i.e. 11 stone 4 = 11×14 + 4 pounds = 158 pounds.
• Chips — what we call fries. What we call “chips” is actually “crisps.”
• Sultanas — Raisins
• Prawns — in the states, a prawn is a type of large shrimp. Here, a prawn is just any shrimp. Prawn is a very popular flavor of potato chips (crisps) here.
• Whilst = while.
• “Half One” or any other such constructs — I once asked a restaurant when they closed, and they said “half one.” Not knowing what that meant, I asked for him to repeat the answer another time. I thought I misheard. Still not understanding, I asked for him to repeat it again. After the third time, I just decided to give up. My friend, who was watching this whole thing in amusement, told me he means “half past one” or 1:30

The mental health service in Blackburn is part of the Lancashire Care NHS Foundation Trust (LCFT), rather than East Lancashire NHS Trust, as is with the other medical specialties in Blackburn. The LCFT is divided into East Lancs (covering Blackburn, Burnley, Darwen, Chorley, etc.), North Lancs (covering Blackpool, Lancaster), and Central Lancs (covering Preston) divisions. East Lancs is divided into Blackburn/Darwen and Burnley divisions. A psychiatric patient who is hospitalized may be sent to any hospital within the trust. Everything is paid for by the government, include hospitalization, house visits, drugs, counseling, etc. Patients are also given some money for daily living.

A patient first sees his/her General Practitioner (GP, equivalent to the “Primary Care Provider” in the US). The GP will then refer the patient to seek help. If the patient is hospitalized, then after their hospitalization, they are dispatched and receive chronic outpatient care by the Complex Care Treatment Team (CCTT). If the patient shows signs of relapse, they are referred to the Crisis Response and Home Treatment Team (CRHTT) for evaluation to see whether or not they need to be hospitalized. The CRHTT are the gatekeepers, and they try to select those patients who need most help to be hospitalized, as there are limited beds, and they try their best to get patients to be treated at home instead, so that there are enough beds at the hospital, and most patients recover better at home anyway. The CRHTT has meetings everyday to review patients to see if they should be hospitalized ASAP or continue being monitored at home. They make house calls regularly and give help to the patients at home. I am currently rotating with the CRHTT, hence the house visit we made today.

During my rotation, I will be rotating 1 week with the CRHTT, 2 weeks with the CCTT, 2 weeks in the regular inpatient psychiatric ward, and 1 week in the inpatient Psychiatric Intensive Care Unit (PICU), which is for patients with extreme or difficult cases. I think this is a good schedule as I will get to see all aspects of the Psychiatry system in the UK, as well as get exposures to all types of patients, from those who are doing well to those who are far from improvement (in the PICU). I really like the preceptor I’m assigned to so far, Dr. Adelekan. He had come to the AUC Clinical Symposium on the island last May to represent Royal Blackburn Hospital and to meet with students, so he was very familiar with AUC and the students. As I am the only student there, he has been teaching me one-on-one, and is more than happy to have me learn. Dr. Adelekan has had more than 30 years of experience in the practice of Psychiatry and he explains things thoroughly and methodically, reminding me a lot of Dr. Nwosu from the island. Just on the first day alone, I feel like I’m getting a lot of personalized attention. From what I hear from my classmates doing rotations in other places, one-on-one time with the attending is something you won’t often find, and so I feel very fortunate to be getting a lot of it.

For each patient I see, I’ll have to do a write up, including patient history, working diagnosis, differential, and treatment, and we’ll discuss it together, kind of like what we were taught to do in ICM on the island. Dr. Adelekan also gives me things to read and study. I will also be attending Problem-based Learning (PBL) sessions every Thursday afternoons with the rest of my AUC colleagues each week to share and present cases that we saw as well as discuss cases and differentials. The hospital has also set up two Sim Man sessions just for AUC students. Each Wednesday afternoons, I will also go to LCFT Teaching lectures, which are attended by junior doctors in Psychiatry to learn certain skills as well as to present special cases in journal club. The lectures are located at Royal Blackburn Hospital’s sister hospital in Burnley, the next town over, so I’ll have to take the free hospital shuttle there.

While I still feel like the awkward newbie, with the funny American accent at the clinic, I’m liking the exposure I’m getting with real patients so far. While we can learn a lot about medicine through textbooks, the patients are our true teachers.

Royal Blackburn Hospital

After an overnight 9 hour flight from Miami to London, then a 1 hour flight to Manchester, and then a 1 hour train ride to Blackburn, and a short 5 minute bus ride, I’ve finally arrived at my new home for the next 6 weeks, the Royal Blackburn Hospital!

My first impression of Blackburn when I arrived by train is the beauty that surrounds the city.  Located in a valley, Blackburn is a cute little town surrounded by gently rolling grassy hills that stretches for miles and miles. The hospital area is located on higher grounds and from here, you can see almost the entire city below. Blackburn is also a very ordinary town, not somewhere you’ll likely find on a tourists’ itinerary. So being here, it’s cool to see what the “real” UK is like and feel like a local!

As I had previously agreed to meet with the program administrator at 1500 (or 3pm), by the time I got to the hospital grounds with my luggage in my hands, I was 17 minutes late, and so I decided to walk directly to the Learning Center where the administrator’s office was. The program administrator was incredibly welcoming and made sure that I was comfortable, and offered another time we could meet up if I was feeling “shattered” (which I’m guessing means “tired” in British English). I was indeed exhausted, but excited nevertheless about my arrival, and insisted that I was ok to proceed with the orientation. She introduced me to many people at the hospital, including the librarians, nurses at Occupational Health, doctors, and other people who work with the students from AUC. Everyone I’ve met here at the hospital have been really nice so far, and I can tell already that they are very happy to have us here. It seems like I’ve found a clinical site with a very positive atmosphere for my first rotation.

After the administrator took me to get my ID made, register with the library, and gave me a wonderful personalized tour of the hospital facilities, just me and her, I finally got settled in my dorm rooms. I am here with 5 other AUC students, 3 of which I know from my class. The other two are a few semesters above me. One of the students has already been here for nearly a year while the others had arrived a week before me and had already started on their rotations. So far, every student I’ve talked to here from AUC have had really great experiences here in Blackburn and say that the preceptors look highly upon AUC students and really enjoy teaching us here, and giving them a lot of clinical hands-on experience. I think this is a great sign, and I’m really looking forward to my rotation.

The dorms here are single rooms, furnished with a bed, bedside table, study desk, bookshelf, drawers, wardrobe, chair, sink, and mirrors. Each room has a heater, and comes with blanket, bed sheets, pillow, towels, and clothes hangers. The pillows are a little flat though, so if you come, I would suggest either buying one here or bringing your own. All of us AUC students live together on the same end of the hallway in the dorms. We each have our own bedrooms, but we share a bathroom (2 showers, 2 toilets), as well as a kitchen and TV lounge. There are stoves, microwave, and fridge in the kitchen, there are plates, silverwear, and cups available for us to use. There is also an iron and ironing board for us to use for free, as well as coin washers and dryers. The showers and toilets are cleaned everyday, and every week, a housekeeper comes by to deliver clean bed linens and towels for free, as well as dump out your trash for you. The rest of the dorms are occupied by UK students from Manchester (University of Manchester maybe?), staff, and doctors.

After I settled into my dorm room and got some rest, I ran into the other AUC students here in the hallway and we all went out for dinner at a local pub called The Postal Order, which was actually more like a restaurant than a bar. Before I came to Britain, I had only known that they ate fish and chips in the UK, and haggis up in Scotland. Coming to this restaurant was perfect because I was eager to find out what real British food exactly was. The first thing I saw on their entrée list when I opened up the menu was their “award-winning” Steak and Kidney Pudding, which was served with a side of mushy peas and chips with gravy. I was amused. I had no idea what it was but I knew I had to get it. In the United States, a dish name like that would have made people lose their appetites… never had I imagined I’d ever see the words Kidney and Pudding together in the same dish name.

As I expected, the dish turned out to be much better than how it sounded to my American ears. While the dish indeed had chunks of steak and minced kidneys (which is so subtle that you probably can’t even taste it if you’ve never had kidneys before), the “pudding” was actually not the chocolate or vanilla-flavored corn-starch glob that us Americans are used to eating, but a flaky-crusted puff pastry, like on chicken pot pie, which was filled with the steak and minced kidney and gravy.  The mushy peas, however, is exactly what it sounds like, sweet green peas, mushed, like mashed potatoes. I already like sweet peas as they are, so I don’t understand why mushing them would make them any more appealing. Nevertheless, I enjoyed it. The chips turned out to be just French fries, which they gave me gravy to dip them in. So yeah, that was my first meal in Blackburn, England.

Afterwards, we went to a really really local pub called “The Observatory.” It’s a really small place with hardly anyone there. The people who are there are all regulars from around the neighborhood. There’s the elderly group that comes in at the same time every night to play dominoes, people who reminding me of my grandma and grandpa. Then, there’s the guys at the bar swaying and singing together loudly to a Coldplay song, karaoke’d by one of their buddies, and then there’s the three kids with the rebellious hair dancing (or maybe just jumping around) to the karaoke’d music on what seems like the smallest dance floor in the world, if you can even call it that, as it also doubles as the place where you play darts (on the single dart board). My fellow AUCers and I played some pool, and some “spot the difference” puzzle games, and got to hang out and get to know each other. When we were on the island during Basic Sciences, we never really hung out in the same social circles or even sat in the same areas in the lecture hall. It’s pretty cool that now after Basic Sciences, we are all suddenly reshuffled, and form new bonds together. I really like our little AUC community here in Blackburn. As we are all here together in a foreign country, we are each other’s greatest supporters.

Royal Blackburn Hospital

The time has come. In approximately 24 hours, I will be in Blackburn, England, jet-lagged, cold, and excited to start my Psychiatry rotation at the Royal Blackburn Hospital! It will be my first rotation ever, and I will be joining a small community of five other AUC students, two of whom I already know from my class on the island.

I’m definitely looking forward to Psychiatry, yet anxious at the same time. When I took Intro to Clinical Medicine (ICM) on the island, we practiced conducting interviews with patients with depression, dementia, and other mental disorders, but the patients we interviewed were all trained actors. Knowing that whatever I do or say now will affect a real person, will I have the same confidence? Will real patients act like the case patients in the textbooks? I will finally find out soon enough in a few days.

Once again, I am going to a new place, and the simultaneous feeling of excitement and anxiety I have now reminds me of how I felt going to St. Maarten two years ago, all over again. It will be my first time in England, and not to mention, my first time in Europe (European colonies in the Caribbean don’t count!). There’s no doubt that things are going to be different: people drive on the left, buy things with pounds (which I have been practicing the past few days to convert in my head to dollars), speak differently than what I’m used to, and use certain vernacular words or phrases that I may not understand (come again?). But having lived in a foreign country the past two years, I know from experience that coming to England and adapting to a new culture and system isn’t going to be too much of a problem for me. If i can survive “The Island,” I can survive this island.

Ribble Valley, near Blackburn

The greatest thing I will miss going to England for 6 weeks is being with my dear wife Irene. Living apart in two different countries the past two years when I was in St. Maarten while she was in Miami was not easy, but it has made us stronger and made our time together even more precious. She has been incredibly patient and I appreciate her so much. These past few months that I’ve been in Miami with her have been a dream. We legally got married, got a new apartment together, took walks at night together, cooked dinner and ate out on our 29th floor balcony together, raised a kitty as if we were parents already, and made friends together as a couple. She is my greatest friend, and I will miss her dearly.

Unlike in St. Maarten, there is a 5-hour time difference between Blackburn and Miami. When I get off my rotations around dinner time at 5pm, it will be noon (or lunch time) for Irene. Perhaps we can have Gung-Ho lunch-dinner dates over Skype! When I was in St. Maarten, time was never an issue as there was either a 1 hour time difference between us, or no time difference at all during daylight savings time. However this time, time seems like a more challenging factor than place in terms of maintaining a long-distance relationship. Nevertheless, I’m not worried about our relationship. We are stable and strong, and know that this short time apart is nothing compared to our lifetime together.

About Blackburn

So here’s a little bit about Blackburn…

Blackburn City Centre

The place I will call home for the next 6 weeks is Blackburn, located in Lancashire county in northern England. With a population of 105,000, Blackburn is about 25 miles north of Manchester, the UK’s third largest city, and 226 miles north of London. I will be flying into Manchester and taking a train to Blackburn.

Blackburn is right in the middle of some of England’s most gorgeous natural regions: The Lake District, Peak District, the Ribble Valley, The Pennines, and Yorkshire Dales (think Harry Potter and the Deathly Hallows). Blackburn is also in close proximity to Scotland and Wales, and just across the water from Ireland and the Isle of Man, making these places very accessible to visit.

The Countryside surrounding Blackburn

The hospital I will be rotating at, the Royal Blackburn Hospital, is a 950-bed NHS hospital located outside of downtown Blackburn. The East Lancashire Hospital NHS Trust, of which Royal Blackburn Hospital is a part, sees 456,000 outpatients and 97,000 inpatients each year and employs over 6500 people. The Royal Blackburn Hospital has new facilities, mostly built in 2006. The Learning Centre on the hospital campus has classrooms, seminar rooms, and an auditorium where we attend Problem-Based Learning sessions, lectures, and skills sessions. As AUC Students, we can do any (or all) of the five core rotations here (Psych, Peds, IM, OB/GYN, Surgery).  The Royal Blackburn Hospital also offer electives in subspecialties in medicine, surgery, pediatrics, and OB/GYN.

Like my other fellow med student colleagues from AUC, I will be staying in the student/staff dorms on the Royal Blackburn Hospital campus, which is awesome because the hospital is just a few steps away, along with the classrooms, medical library, cafeteria, and gym.

So with my passport in hand, and First Aid Psychiatry to read on the 9-hour flight (Thanks Sameeksha for the book!), I’m ready to roll! See you on the other side of the pond!

Benji

To prepare for this transition, I highly recommend going to the townhall meetings and talks hosted by the Office of clinical affairs when they come down to the island every semester. Not only is there useful information, but you can also meet the clinical advisors with whom you will be working so that you have an idea of who they are in person (and vice versa) during the transition. It’s important to meet them in person because you may not have another chance to do so once you leave the island (after which you will only be able to communicate with them via email or phone). I also highly recommend going to the clinical fair during May to meet with the clinical directors you may be working with.

As for me, I have finally confirmed my third year rotation schedule. For my first rotation (in less than 2 weeks), I am heading across the seas again, this time to the United Kingdom, where I will be doing a 6-week clerkship in Psychiatry, followed by the rest of the year of rotations in Miami. I am very thankful for this opportunity to finally begin learning the tricks of the trade in a real clinical setting, as well as the invaluable opportunity to experience the medical systems of two countries, and I am looking forward to this new phase in my journey.

Here I have laid out a checklist of the things that need to be completed from the end of Basic Sciences until the start of clinicals.

1. Attend the Fifth Semester Clinical Orientation hosted by the Office of Clinical Student Affairs (OCSA) during fifth semester. During this orientation, you will fill out and sign an Official Leave Request Form to cover for the 4 months (1 semester worth of time) that you will be on official leave to study and take the USMLE Step 1 exam.
2. Once you have passed your first NBME Comprehensive exam on the island, you will be given permission to start registering for ECFMG by the school. The first thing you’ll have to do is to go to the ECFMG website and then register for a USMLE/ECFMG ID# as well as complete the online part of the ECFMG application. To start, go to “Online Services” on the Homepage menu, and then “IWA.” Establish an account with ECFMG. They will email your ECMFG Number. You can use this number to log in and out of the ECFMG site.
3.  After you fill out the online application, print out Form 186, fill in your information, and attach a passport-sized photo of yourself on the form. You can do this on the island with the Dean of Academic Affairs (Dr. Yoshida), and the school can print out a passport-sized photo of you from y0ur student ID photo for free. Turn in your Form 186 to the Dean of Academic Affairs or the Registrar.
4. Next, login to your ECFMG account to register for the USMLE Step 1 on the site, and pay the fee. Wait a few days to receive your scheduling permit for the exam.
5. Once you get your scheduling permit for the USMLE Step 1, go to the Prometric website and then schedule your Step 1 exam. The exam can be taken anytime throughout the year and anywhere in the United States, as long as there is availability at the specific prometric site where you want to take the exam.
6. After you set up a time and place for your Step 1 exam, contact OCSA of your registration date.
7. Study really hard.
8. Take Step 1. Remember to get plenty of sleep the day before the exam. The exam is 8 hours total (7 one-hour sections and a 1-hour break). Remember to bring your scheduling permit and drivers license (or some sort of government-issued ID).
9. Go home and celebrate that you are done with the exam. Get some rest.
10. In the meantime while you wait for your scores, get your titers, ppd, physical, and flu shot done. Print out the Health Statement form from the AUC Clinical page and have it filled out by your doctor. The ppd is a 2-step ppd, each done one week apart from each other. Once you complete your health form, send the filled-out paperwork as well as a copy of your lab results to your advisor. You can also scan the paperwork and lab results and send it via email. Your health form and immunizations must be updated every 12 months. It costs anywhere from $200-700 (depending on which clinic you go to) to get these forms/immunizations updated.
11. You will receive your Step 1 score on the third Wednesday after your exam. You can go on the ECFMG website (Online Services –> Oasis) to check your score status. You will also receive an email telling you your scores are ready. Your scores will be in a pdf file posted on Oasis.
12. Immediately download and forward the pdf file of your score (on Oasis on the ECFMG website) to the clinical office. In the same email, list your top three preferences for regions where you want to do your rotations. Also list your phone number and when you would like to start your rotations. Be sure to use your AUC email.
13. One week after you receive your Step scores, you will receive a phone call from a clinical advisor to let you know what clinical sites are available and to schedule your core rotations. You can take some time to think about how you want to schedule, according to the choices available. You can also decide to schedule your first few rotations now, and then decide on the later rotations at a later time. Once you decide on where and when you want to do your rotations, officially confirm your schedule with your advisor via email so he/she can start processing your financial aid.
14. Do financial aid — 4 things to fill out: FAFSA, MPN’s for Stafford and PLUS loans, and Request for Direct Plus Loans (credit check). Afterwards, you will receive your financial aid award letter, which you sign and return to the AUC Financial Aid Office. You’ll only need to fill out FAFSA once a year, but you must fill out the two MPN’s and the Request for Direct Plus Loans every semester during clinicals (vs. Basic sciences, where you just do it once every two semesters).
15. Have your advisor initiate a background check for you. He/She will send you a custom link, in which you go to a website and fill out the information.
16. Fill out the Registration Form, which you can download from the AUC Clinical Page, and send it to your advisor. You can also scan it and email it to your advisor. Registration Forms must be filled out each semester.
17. Make copies of your drivers license, passport, and CPR card, and send them to your advisor. You can also scan it and email it to your advisor.
18. Finally, the site director or coordinator will contact you and give you further details on the rotation you’re about to start.
19. In the meantime, look for accommodations, flights, or travel plans, and connect with classmates who will be in the same clinical site (Consider joining one of the several clinical Facebook groups here). You may also want to brush up on your medical knowledge while you wait anxiously for your clinical rotations to begin. If you are rotating in Miami, brush up on your Spanish skills. Some hospitals may prefer you not wear your AUC white coat. In this case, shop for a few new white coats. In the UK, they may prefer you not wear a white coat at all, for sanitation reasons.
20. Start rotation. Learn. Have fun.

My new books!

Now that the step is over, I’m playing the waiting game… waiting to schedule my rotations and waiting to start clinicals.  I feel like this entire semester has been a semester of anxiety: I’ve been anxious while studying, anxious during the test, anxious after the test, anxious waiting  for scores, and just when I think I get a brief moment of relief after getting my scores, I’m anxious again as ever, starting this entirely new phase in my med school career. But nevertheless, I’m pretty excited and looking forward to it.

It’s strange not needing to study again for a while. In the meantime, to get my anxiety off, and to pass the time, I’ve taken up a few activities:

1. Brushing up on my Spanish

As I am aiming to rotate in Miami, I feel it is a good investment of my time to brush up on my Spanish, as many patients here speak Spanish as their first language. In fact, Miami is unique among the major cities in the United States in that the majority of its residents speak another language besides English at home. While most everyone can speak English, 67% also speak Spanish and 5% speak Haitian Creole. Only 25% of the residents of Miami speak only English as their first language. Therefore, it’s a bonus if I am competent in Spanish.

I have taken Spanish in middle and high school, and while growing up, my parents understood the benefits of starting language education early, and hired local college students to teach my brothers and I Spanish several times a week for many years, starting when I was young. Ever since high school, I had the opportunities of traveling and using Spanish in countries like Mexico, Guatemala, and Puerto Rico, and I also volunteered in a pediatric clinic where the majority of patients were Spanish speakers, and so I had never really forgotten Spanish.

I’d like to go beyond simple conversational Spanish since I will be conducting entire interviews as well as educating patients, and to do this, I would need better fluency. On the island, I’ve participated in Latino Medical Student Association’s Medical Spanish Workshops where I’ve practiced conducting entire interviews in Spanish (which was quite challenging for me). I’ve also been reading a few blogs in Spanish as well as using Spanish whenever I can here in Miami. I also downloaded this app on iPad that helps me in medical Spanish.

2. Studying

Following advice from some of my friends who are already in clinicals, I’ve bought a few books that would come handy during my clinical years:

• Step-Up to Medicine (Step-Up Series) — This is the book that I hear “everyone” is using to prepare for the internal medicine shelf. I hear that it is also very useful for other fields as well.

• Step-Up to USMLE Step 2 (Step-Up Series) — oh my goodness… studying for Step 2 already?? Many people have told me while First Aid for the USMLE Step 1 was awesome in preparing you for Step 1, First Aid’s Step II prep book doesn’t nearly do the same job. It seems like the book that more people  prefer is Step Up to Step 2. Like First Aid, it’s well organized and comes with a lot of mnemonics and charts, but it also seems like it has more practical detail, which is what is more important in clinicals.

• USMLE World Step 2 — like USMLE World for Step 1, this is a question bank that will help me prepare for my shelves and Step 2. For Step 1, I made the mistake of starting too late on doing questions. This time, I’m going to start early on questions, so I can go through them at least once.

• Rapid Interpretation of EKG’s, Sixth Edition — We’ve been learning about EKG’s for a long… there was the EKG workshop that AMSA puts on every semester. There was Dr. Lewis’s lectures from Physio I during second semester. And then more EKG during Path, ICM, and Step studying. Although during our first two years of med school we have had a lot of exposure to EKG’s, it still takes me some time and effort to interpret an EKG. What I want is to develop a “rapid interpretation” of EKG’s, as the title of the book says. Apparently this book is very helpful in solidifying your practical knowledge of using EKG’s in the clinical setting.

• Pocket Medicine: The Massachusetts General Hospital Handbook of Internal Medicine (Pocket Notebook Series) — This is a handy little spiral-bound pocket guide with info that you can look up on the spot during your clinicals. Again, this is something that “everyone” tells me to get.

3. Wedding Planning

Although Irene and I legally got married in the courthouse earlier this semester, we’re having a traditional ceremony and celebration with close friends, family, and relatives from abroad. I’ve been in charge with making the website, finding a photographer, finding hotels for our guests, and more. Planning can be hectic, but it can be fun too, and I’m glad that I’ve been blessed with having a “break” to work on the wedding with Irene.

4. Piano

When I was on the island, I’ve always said there were two things I missed. One is, of course, Irene, and the second is my piano. It’s finally great to be back with Irene again. When I went home to Georgia this past Thanksgiving, I also finally got to see my digital piano again. After some struggle, we managed to fit it in Irene’s car and brought it back down to Miami, so I can play it whenever I want to. Most of the time, I like to improv and play by ear, but sometimes, I also like learning new pieces. Currently, the pieces I am working on right now are:

• Prokofiev’s “Diabolique Suggestions” –  I played this Prokofiev piece when I was in high school. The piece sounds hideous to the ears but I find it so fun to play that I’ve decided to re-learn it.

• Liszt’s “Un Sospiro” — This is a piece I half-learned before I came to med school. Now, I’m picking off where I ended and trying to learn the rest. This piece is absolutely beautiful and with all the hand crossing-overs in this piece, it’s also fun to play.

Cheers,

Benji

At AUC, in order to finish Basic Sciences, every student must pass the NBME Comp as well as a Kaplan Comp, to ensure that we have acquired sufficient medical knowledge to at least pass the Step. Most everyone in my class passes the Comps. After leaving the island, we have a semester’s worth of time to further prepare, improve, and take the Step (which is about a three month period).

For me, the main resources I used to study for the Step are First Aid and USMLE World. I also met with a group of my classmates from school over Google Plus Hangout every day for several weeks, and together we’d go over the material in First Aid, following a strict study schedule that we had set up beforehand. Each of us would also use other different study sources, like Goljan Rapid Review, First Aid Cases, or Doctors in Training videos, and whenever we met together, we would fill each other in with extra information that we had come across from our studies, while annotating that extra information into our First Aid books. After we had finished going through First Aid, we then started meeting every other day to share interesting practice questions that we had come across, and then discussing the information pertaining to those questions. It was very useful, and makes you remember things better when you discuss it.

USMLE World (“U World”) is an online question bank that contains over 2000 USMLE-style practice questions. The format of the program is exactly the same as that of the real Step I exam. Each question has a really nice answer explanation, and the questions integrate different disciplines and involve a high level of thinking. You learn so much just from reading the explanations in the answers. I highly recommend subscribing to USMLE World when you’re preparing for the step. For the most part, I felt the questions in Step 1 was more straightforward and easier than USMLE World questions. Although I unfortunately didn’t get a chance to go over all the questions more than once (although I wish I did), I and many of my classmates highly suggest going through the questions at least twice.

First Aid for the USMLE Step 1 (“First Aid”) is a review book that covers the most highly tested concepts on the Step. The charts and lists in the book are very useful, and the book provides a lot of mnemonics to remember details you need to know. Because it only covers the high-yield concepts, First Aid is the least you need to know for the Step. It’s important that you go over the book several times from cover to cover. Memorize the book.

Although First Aid and USMLE World are great resources for prepping for the Step, I found that a lot of questions on the Step I was able to answer not because I learned it in First Aid, but because I remembered learning about it in class. Review books like First Aid may help you pass, but to excel, you need the valuable education you gain from school. Therefore, the most important factor for your success on the Step is learning the material well the first time during lecture, and at AUC, you have two years of access to professors, labs, lectures, TAs, books, and fellow classmates and friends to make that happen. The preparation doesn’t start after you leave the island. It starts from Day 1 of medical school.

Good luck everyone!

Benji