Today I spent my shift shadowing a doctor who had just finished her foundation training years and was planning on spending this year in the Emergency Department. It was very interesting to experience the delivery of healthcare from the perspective of a doctor who was fairly new to the profession as opposed to somebody more experienced, (like the doctor from my last shift who had been practising for 25 years). Today I only saw one patient as this patient required more attention than the patients I had previously seen and many different members of the healthcare team needed to be contacted. I also noticed the differences in the way the two doctors approached their patients as my previous doctor was more direct and to the point, however, today’s doctor was more meticulous and thorough.
Before we went to call the patient, the doctor told me that she wasn’t too keen on doing an eyes patient, but she must still do it as she has to work down the list in order. I was quite intrigued by this as I had also heard another doctor say the same thing last week, so asked her why most doctors don’t particularly like doing the eye patients. She told me that it’s because in Medical School you only spend about two weeks on the eye and many doctors feel a little incompetent in the field. This made me wonder as to whether an optometrist would be better suited for this role within hospital rather than the doctors. Nevertheless, the patient was called in along with her daughter who had accompanied her to the hospital. The patient was a an 80 year old lady who had discovered a lump under her eyelid and was experiencing a loss of vision in that eye.
I noticed the way the doctor asked her some very specific questions in order to rule out certain conditions. The answers to the questions were quite hard to interpret as the lady was giving one response but her daughter was shaking her head and contradicting it, such as when asked whether she has headaches the patient denied that she has had any headaches, however, her daughter said that she had been complaining about headaches for the past week and told her that she was worried in case she was going to have a stroke. This occurred with quite a few of the symptoms, with the patient still refusing even after being contradicted. In this situation I could see that the doctor had to make a fair judgement without appearing to alienate or ignore any of the people involved in the consultation. She had to take in to consideration what was said by them both in a respectful manner. I am able to reflect on the challenge of this as a doctor as it may be difficult to see who is not being entirely truthful. Sometimes patients may not want to appear as too much of a problem and may play down their symptoms, or similarly they may over play their symptoms under the impression that they will receive better care or medication.
I am able to reflect on the observation that this doctor wrote the notes during the consultation, unlike the previous doctor I was shadowing who wrote them all after. I can see that this is due to personal preference. If the notes are written after, it’s important that you can remember what the patient said and are able to recall all the details. Similarly, if they are written during the consultation, you have to be careful with your communication ensuring you still maintain eye contact and pay physical attention to the patient so it doesn’t appear off putting that you’re just scribbling down their words. As a doctor, it’s very important that you are aware of your own strengths and weaknesses.
After the questions, the doctor then physically examined the patient. I was able to see an Opthalomascope in use in an actual clinical setting after learning how they are used. The doctor appeared to be twiddling with the wheel on the side of the equipment which I interpreted as being the refractive index that I had also learnt about earlier. I found it quite interesting to see the physical examination take place: her eye movements, focus points, pupil dilation were all tested along with her sensitivity to touch and grip in order to help identify any problems with the brain. I also learnt that all examinations aren’t necessarily straight forward and can be a little bit of a struggle as this patient was slightly difficult to test as she had was partially deaf so couldn’t hear the instructions properly and just generally was a little bit chatty and wouldn’t remain still or focussed on a particular point when asked. This allowed me to appreciate the skills needed for a doctor to excel in what would appear to be an ordinary consultation.
During my time spent in the consulatation I also identified the need for the vital skills of versatility and ability to adapt to new environments as a doctor. For this doctor, it was her first time in this hospital and she admitted that she wasn’t exactly sure how to use the eye machine as each model is a little different, but when in the room in from of the patient she had to adjust to her surroundings and apply all her knowledge in order to allow the consulatation to run smoothly. I was really mesmerised by this doctors ability to do this and I truly value the posession of this skill.
After the examination the doctor said that she thinks that the lady’s cataracts may need to be looked at in the future, but that this isn’t necessary at the moment. Apart from this, she couldn’t explain the lump or the sudden loss of vision in the patient’s left eye, so she called the Consultant to come and give another opinion on the patient. This experience allowed me to recognise the importance of working in a team and I am able to reflect on the significance of asking for help when you need it. As a doctor, you should not be afraid to admit that you are wrong or that you don’t know rather than making something up.
I was also able to watch a line being put into the patient’s vein so blood could be collected for some blood tests. The samples of blood were sent off to the labs to be tested. I learnt that the blood normally takes about one and a half hours to be tested and results retuned for the emergency wards. I thought this was quite good as it wouldn’t be ideal if we had to wait a set if a patient is in an emergency state. The doctor told me that she is suspecting that the patient may have had a stroke in one of the blood vessels leading to her left eye which could have caused her loss in vision. She then explained this to the patient, I think this was very important because doctors should always be honest and apparent to a patient about their condition. She also explained to the patient that they aren’t sure about this diagnosis and are contacting an Opthamologist and the Stroke team to give them some guidance on what her symptoms indicate it is. She was told that she could only be referred to the Opthamologist of it is a problem with the actual eye, that’s why they needed to find out whether it was the eye or the blood vessels behind the eye. I am able to reflect on the way the emergency doctors cooperated with professionals with specific specialities and I thought this was the most effective way to provide care for a patient.
As we were waiting for the results from the blood test the doctor decided to cheek the patient’s blood pressure. She took two measurements as I saw the doctors in the Surgery. Both the readings were incredible high, over two hundred. This was clearly a cause for concern for the doctor and she said that high blood pressure is often linked to strokes. She told me that she may have to provide her with some Medicine to lower the blood pressure, but she must be careful not to suddenly lower the blood pressure as this can cause problems in itself – the brain could feel starved of blood and therefore oxygen and not function correctly. She said the drugs must be administered slowly and then made to increase so her body isn’t left at show. This allowed me to understand the importance of considering the effects of prescribing medicine rather than just prescribing it and not thinking of any consequences…sometimes it’s about how the medicine is taken as well what type of medicine it is. You should be very aware of how you can lower any negative impacts can be lowered for all your patients.
Unfortunately, this patient’s problem hadn’t been fully diagnosed by the time the doctor’s shift had finished so she had to pass her on to another doctor and I was able to experience the handover. I noticed the way the doctor summarised everything that had already been identified, the fact that we were waiting on the blood test results and also the other members of the team which had been contacted. This pass over to another doctor allowed me to reflect on and appreciate the need for well written and accurate notes so other people are able to update themselves on a patient.