Survival Guide for Medical Internship

7/26/2019 Survival Guide for Medical Internship

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SFL+ past internsPhysical Psycho Social Spiritual Survival Guide to Internship 2014 a

This is mainly a psycho-social-spiritual guide, born in summer of 2011, out of an urge to address (in HA

jargon) an unmet need. This is meant to complement, rather than rival, other excellent advices to interns.

It has been extensively re-written in the summers 2012, 2013 & 2014, growing from 2 pages to 16 pages,

with continued input from practicing & past interns, & residents. SFL is esp thankful for the heavy inputsfrom Drs Zenon Yeung, Rutherford Sin, Ray Leung, CH Au, Crystal Mak, Anthony CC Chan, YC Lee, Tiffany

Wong, Jacky Ho, Tiffany Yeung, James Chow, J Yeung, J Chan, Emily Wong, Jo Lam to this guide. This is

meant to please tell me your comments next summer (& anytime earlier) to enable this guide to

evolve into a broader platform for sisters & brothers to share experience, address & resolve problems of

present day practice. I believe that being a doctor in 2014 is exciting & rewarding, if we can overcome some

under-addressed problems of our era. Suggest that you re-read this document after 1 month of starting

internship. SFLs survival guide to Yr1 residency 2015 is also available next summer.

Part I:THE THREATS

Get prepared for the threats & disillusions, by psychological tuning

1. Set the correct default settings(ie set the thermostat of expectations: what is appropriate, too much,

or too little workload?). Reference standard: Work from 7:30am to 7pm each day. Have breakfast, no

lunch, have dinner; always in multi-taskmode (need to handle >=2 things at the same time), On call:

sleep 0-4hr depending on where you are working in. Anything more tough than this is relative

hardship. If you have time to take lunch, if you can leave work at 6p, if you need to do only one thing

at a time, and if you can sleep more than 2h while on call - you are blessed. Thank God for the LUXURY!

2.

What is the workplace like?Please view the first 30min of the movie Saving Private Ryan, whichshowed a battlefield covered by bullets pouring in from all directions, upsetting all your pre-plans. The

workplace is a battlefield, full of unexpected, accidental happenings involving many many people in an

uncontrolled manner. ANYTHING can and will happen and you will be expected to handle it regardless

of whether you know how to or not. Rule of thumb: if no accidents occur, it is an accident. The tasks

do not necessarily come in an orderly, reasonable manner. You are a soldier. When on call, nobody

will show you empathy or pamper you, people will tell you to do a never ending list of urgent tasks

and expect you to do it immediately, you may be deprived of your basic needs - sleep and food.

3.

Nature of work:70% of time doing clerical & technician work (book investigations, write medications,

write out already-decided orders, take blood, put on iv drip), 30% of time acting like a doctor (handle

unexpected small and big problems from patients, talk to patients and relatives, admit patients & take

history, physical exam and investigations). Should we be disappointed? Yes and No. But if that 30%

time of being a doctor is already very stimulating, it's still a big gain. Do treasure it. Also, being the one

who stays in ward the longest time, often housemen can pick up tiny little things that MO would have

missed. Dont go to the extreme & indulge in being a clerk + technician & give up the Doctors role!!

4. Interacting with nurses. Nurses turn to houseman when they encounter any sort of problem from

looking at lab results, dealing with patients clinical deterioration, or interviewing difficult relatives or

patients. They may call you to deal with the most trivial things during the busiest hours, e.g. report

insignificant findings of HbA1C 8% (sometimes reported as Hb level!), Na 132 in the middle of night

while you are resuscitating patients. Stay Calm & dont get mad: theyre innocent: please understand

that (a) theyre only taking care of patients in their cubicle/ward & would not know all the problems

youre dealing with in the other wards (b) actually most of the time theyre blocking even more trivial

& non-specific ward complaints; and without this help your on calls would be 100x more miserable,


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you simply dont know it because you never get informed about these (c) therere many things they

cannot do/ decide/ prioritise for you, & if theyre doing so its just a bonus to you but this should not

be taken for granted, (d) words on your performance & temperament, be it good or bad, spread much

faster than you think in this small medical circle, your reputation would come back to help you (or

haunt you) at the least expected moments. Always think twice when youre going to make enemies;

most of the time it is a bad idea in the long run. Always call back IMMEDIATELYonce you get a calland then prioritize your tasks. Inform the nurses what you have been doing and reassure them that

you will help them very soon. All in all, respect them and their work because they are as important as

doctors in the hospital. Can I take the nurses advice regarding the urgency of the task? You have to

judge. Some nurses are very experienced and make very timely suggestions to us, while some may

scold you to do something immediately and cut you off. Learn to have a fine balance in listening to

their suggestions as well as having your own judgment.

5. Responding to patients and relatives enquiries. After history taking the patient may ask you about

their diagnosis or prognosis. Some interns would adopt a defensive approach and refuse to comment.

This is understandable as youre relatively inexperienced & theres a risk of making the wrong

diagnosis or giving the wrong message; but on the other hand it is no good rapport to leave thepatient completely in the dark and push all the responsibilities to the MO. One possible approach is to

say CLINICALLY the diagnosis might be xxx but it might also be yyy, we have to wait till your case MO

to see you to confirm. When being asked what is action plan, you can mention things that cant be

wrong such as blood check, sputum/urine culture, monitoring. It can be troublesome if you say the

patient needs an MRI but later the MO decided that the patient doesnt need one, When asked about

investigation results, it is ok to tell them that the Hb is 12 or the sputum grew a bug, but be very

careful about serious diagnosis such as cancer, as breaking bad news requires a lot of skill and

appropriate timing is of utmost importance. The MO may like to do it in presence of the relatives and

may prefer to do it by himself/herself; you may have to say please ask your case MO as he/she

knows your situation better and would explain to you. When youre asked to certify a dead patient,

often the relatives would be around. It is courtesy to gather the relatives, tell them frankly that thepatient is dead (see appendix 1 for a sample of the conversation).

6.

Interacting with difficult relatives. I bring up this issue specifically because of its potentially serious

harm to your professional life. Even one case of unhappy interaction can continue to upset you for

several days, or even make you lose your morale and change your view of medicine, ultimately

destroying your ideal and dreams. Remember. Remember. Remember! The communication is often

merely an emotional expression, i.e relatives verbalizing disappointment and anger disguised as an

argument, while the doctor falls into the trap of arguing the factual details. If somebody sings a song

to express his feeling, you can echo the song, but you dont need to argue about the logic of the

songs contents. You may just repeat the previous answer, or talk about something else without direct

answering. You may give the relatives something to do as a distraction (eg buy lunchbox if it is aftermealtime, bring back private medications/ lab results, ask other relatives to come etc). Nurse sisters

are of enormous help in these situations. Stay calm in front of angry relatives/patients. Try to stop the

conversation if you become angry. Wash your face and come back. It will be much better!

7. When you go mad/ breakdown The most common situations for this to happen are: (a) youre called

to do the 3rd

& 4th

& 5th

tasks urgently while youre still struggling with 2 urgent tasks at the same time,

you have a feeling of being driven to madness. Solution: Remember, bullets in the battlefield do not

fly onto you according to an orderly reasonable timetable, so be psychologically prepared. Switch

your mind to this mode: I know you want to trap me, to kill me, but Im not easily killed. Im going to

set a record to my CV of handling n tasks at the same time: this is my track record (b) when you face

unreasonable relatives (Solution: see above).


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8. When called to handle several tasks at the same time. All interns suffer from severe time shortage.

There are simply too many tasks and too little time to complete them all. The key to handle the

problem is PRIORITIZATION.

(a)

Identify task that potentially can lead to consequence and attend to them first, then leave theminor and non-urgent tasks later.

(b) When the nurse calls, it helps to ask a few quick questions to gauge the scenario (see examples

below) (but don't use more than few min asking for details over the phone: if you found the case

complicated, it is probably better to attend it anyway)

(c) For every complaint, assess the GC and look at vitals first. Do resuscitation and call MO

immediately for serious case.

(d)

Always have the houseman handbook handy. Before starting internship, flip through the

handbook to at least know what topics it has covered.

Tasks can be classified into 4 types: urgent & important eg resuscitation, unstable patients eg desat,

low BP, urgent admission & urgent ward complaints, urgent blood test eg pending start of antibiotics,certify death; urgent but not important eg prescribe discharge medications; important but not

urgent eg non urgent blood taking, non urgent admission & ward complaints, printing job sheets,

rewrite drug charts, non urgent & not important: eg screening non-urgent lab results. Prioritise in

that order.

9. Common urgent complaints (see Appendix 10 for details)

10. Less urgent tasks

Booking imaging

Organize with the framework: [relevent past history] + [HPI] + [relevent P/E and Ix] + [your concern]e.g. Good past health, Admit for chest pain, ECG sinus tachycardia, ABG type I resp failure, TnI pending.

For contrast CT thorax to r/o P/E

e.g. History of renal stone with ESWL done, Admit for fever, noted right loin tenderness, elevated Cr

90 -> 180. AXR no opacity. urgent USG urinary system for hydronephrosis

If youre very busy, just point out the main point, get this clue by reading the notes of the same day,

then previous progress notes. For urgent requests, ask the case MO if youre not sure why its urgent.

If you don't know, youll be rejected by the radiologist and you have to go back to him/her again which

is waste of time.

Writing referrals. Use the framework similar to booking imaging.

e.g. To Urology COS: Thanks for see the patient! This lady with HT and DM was admitted for UTI, urineC/ST showed E Coli and was given Augmentin. USG kidney noted a 4cm complex renal cyst at left

upper pole with mural calcification and septation. No hematuria / dysuria. urine cytology pending. An

CT kidney has been booked. Please kindly see this lady to rule out kidney malignancy. Thanks!

Typing Discharge Summaries If youre very busy, focus on the main treatment received and the

result. Imagine you are the MO in another hospital E admitting this patient later: what are the key

points that need be clearly stated for his/her reference?

11. Psychiatric complaints are common in medical wards. You can assume that: In any medical ward,

theres always one or more patients with psychiatric problems. We sometimes think like a layman &

see psychiatric complaints being unreasonable. Try to see it as an interesting challenge rather than a

nuisance. See Appendix 2 for tips for making diagnosis and tackling two common problems.


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12.

Traps waiting for you (1): wrong patient identity: you had been reminded n times on this already. Be

particularly attentive when(a) taking cross match (b) prescribing any medication -- also check allergy

(esp augmentin as it is commonly used and has cross sensitivity with other beta lactamase inhibitors)

(c) upon resuming usual medications dont just read the hard copy of ePR the nurses printed for you:

check the name yourself, or go thru electronic ePR yourself. Click next patient whenever each job isfinished. While youre working on the CMS on Patient Asuch as making requests for investigations,

somebody asked you to check/do something for Patient B. You close Patient As file and open Patient

Bs file. After you have dealt with Patient Bs case, you may forget to close Patient Bs file and then

make requests & type medications for Patient A on Patient Bs file.

13. Traps waiting for you (2): forgot to remove the tourniquet Youve been reminded n times on this

already. Note that some patients may not be able to complain eg demented patient their arm &

your license would be lost. Please establish a reliable routine for you to check this every time. Dont

use the disposable-plastic-glove as tourniquet - they tend to be overly tight, and one could easily

leave it on patient's arm due to their disposable nature.

14. Traps waiting for you (3): x-match in a row There are times where one needs to take crossmatch

blood for a number of patients (e.g. In pre-op surgical ward). It is safer to printout the job sheet and

take blood patient by patient, instead of printing out all jobsheets together and go take blood in a row.

This is slightly time-consuming, but it also kills the tiny possibility of a wrong crossmatch - a medical

incidence which is strictly unforgivable

15. Dont take signing of consent forms lightly. Make sure you did explain properly the potential

complication of the procedure, they can occur. If the consent forms for contrast CT / Endoscopy are

deemed inadequate (eg. did not mention the side of procedure, left out important complication)

when the patient arrives for the procedure, you may be asked to go to the center to amend it: a big

waste of time.

16. Blood taking Acquire this skill ASAP as it may rate-limit your job. When taking ABG from femoral

artery: don't take blood above the inguinal ligament which would increase the risk of uncontrolled

intra-abdominal bleeding. Dont leave the tourniquet tied on the patient.

17. The start of 2nd rotation Unexpectedly, some interns reported that they have a feeling of

disorientation at the start of the 2nd

rotation, this is because the specialty is new, the routines are

different, the culture of the unit is different. Get psychologically prepared for such to minimize the

problem.


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Part II: Some GENERAL PRACTICAL ACTIONS

1. Always be nice to your colleagues, seniors and nurses. These days people around you are generally

very nice and ready to help you. Try to help your colleagues after finishing your own work. Being

helpful is a good way to make friends and if you have the need in the future with large amounts of work

to be done, they may even return the favour.

2. Make sure to save a copy of Houseman Handbook/ Common Treatment Order in your smartphone. It

will be of great help at night when you are stuck.

3. Make every effort to do ward rounds in the morning or admit cases before the MO as you feel more

like a doctor this way. Also this is the best way of knowing what the clerical work that follows is all

about. Clerical work is easy to pick up e.g. booking investigations, taking blood, setting drip, but the

decision making and clinical judgment is really what we need for the coming years. We learn best when

the interns orders when admitting or rounding a case is counter-checked by a MO. Most of the clerical

work actually helps you train to be a better MO in the future. For example, it seems very tedious to

transcribe medication but it is in fact a great chance for you to learn the dosage and frequency of somecommon drugs! Try to think positively!

4. It is very impressive to be able to present cases or to participate in operations during your internship.

This will allow the MOs to know that you are keen and want to go into the specialty. However,

remember that the first priority is to finish all your ward work and to be responsible . It is definitely

not a good sign when an intern is showing how keen he/she is to the MOs but are leaving all their own

work behind. Word gets around and MOs will know leaving a very bad impression.

Part III: more about SELF CARE

1.

Do socialize outside the circle. Youll have a tendency to be deeply immersed in your work experiences

& socialize with your medical friends all the time. But dont forget your family and friends outside. The

lonely old folks you saw in the hospital may remind you that your parents also dont have much chance

to see you these days while youre always busy. Do treasure every meal with them while they have the

well-being to enjoy so. Find a time to meet your old classmates in primary & secondary school: they are

engaged in different positions in society & can keep your view broadened outside the ivory tower.

2. Do eat. You would feel that your patients are more fortunate than you as they are guaranteed 3 meals

a day & a full nights sleep, while nobody care about your well-being. Thus you have the responsibility

to care for yourself. Do take your meal anytime, even if theres only 15 minutes; if you dont have 15

minutes, nip a bun or a chocolate bar, so that you can go on. You need to fulfill the basic life needs. If

you collapse, youre not the only victim, your patients would be affected, your workmates then getmore work & then join your collapse, and.

3. When you are on call and are exhausted from work, try to think this: there are around colleagues

from your class (plus those over-harbor, not to mention countless number of MOs) who are also on

call now. You will feel much better. Also, there is always an end-point for every call!

4. Plan your holiday. To make the hard daily routines & life more bearable, you may now & then

think/plan/fantasize on a plan for your next upcoming holiday, instead of seeing your holiday as

sleeping days. Do consider annual leaves for a genuine leisurable holiday and dont overlook the

importance of these recharging times. If you decide to go for attachment, consider doing it BEFORE

internship starts; if you have to do it during internship, you may consider limiting it to a short 3 dayattachment and leave some good time for rest.


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Part IV: JOB HUNTING

1. Introductory information on Specialties. See Appendix 5, 6, 7, 8, 9 for introduction to Surgery,

Emergency Medicine, Psychiatry, Ophthalmology, Anaesthesia/Intensive Care. Note: the trainee period

only represent a relatively small segment of your lifetime career, its the long term environment and

nature of work as a specialist which matters more. Although its easier for you to gather information

and tips from the young trainees who are more close to you , its relevant for you to seek sharing from

the specialists, esp the young specialists who had completed their professional exam and looking ahead

2. Professional exams. In some specialties, professional exams can be undertaken during the internship

year. Surgical membership exams, for instance, take place twice a year in September and in March. It is

worthwhile to plan ahead because very often interns are just too busy and tired to pick up their books

again. As a result, the passing rate is fairly low around 60%. Having passed these professional exams

put you in a better position when you are looking for a job because this means you will be more likely

to be able to complete your basic training on time and you will take less study leaves when you are a

MO.

See Appendix 3 & 4 for introduction to MRCP exam & MRCS exam.

3. CV and cover letter. CV and cover letter should be ready by the end of December. Some specialties e.g.

radiology, anaesthesiology tend to start their interview early i.e. in December, while surgery and

orthopaedics interview tend to be in March or even April.

4. Intern assessment report. Intern assessment report is the single most objective way to reflect how you

work as a doctor. It tells the employer how you work with your colleagues, how hardworking and

responsible you have been. Most of the fresh graduates may think that only distinction candidates can

get a good job. This is not entirely true! Candidates who are hard-working, responsible and smart are

also very eye catching. So dont give up if you havent got a distinction in medical school. Internship is a

year for you to catch up and to impress everybody with your hard work!

5. Attachment. Many interns apply for clinical attachment during their annual leaves. Since these clinical

attachments are usually quite short, lasting for just a few days, it is not certain how much impact they

have on your employment. However, it may be useful to get a more in-depth feeling of how working in

that specialty is like. If you decide to go for attachment, consider doing it BEFORE internship starts so

that it wont consume your annual leave; if you have to do it during internship, you may consider

limiting it to a short 3 day attachment and leave some good time for rest.


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Part V: THE ENJOYMENTS(dont be blinded by fallacies & miss the treasure)

Fallacy: The intern is at the lowest position in the ladder

Fact: The intern is HIGHEST in terms of satisfaction (Army Camp mode of work gives you good physical

exercise, a good appetite to eat and a good appetite to sleep), intensity of learning (the things you learn

gives you a sense of increasing power) and memorable experience (the variety and number of people you

meet, all at important moments of their lives, is many times more than the sum of all the people you have

met from the day youre born to the day before internship), lack of mental stress (surprisingly, many ACs

and consultants these days became more unhappy after promotion, and in the extreme case has to leave

HA), enjoyment of off-duty life (the longer you stay in the ward, the bigger the contrast), and the buying

power of salary. Unfortunately such good days last for only a year.

Fallacy: The intern tends to be bullied by all parties, being the lowest animal in the ward

Fact: These days people around you are generally very nice and ready to help you.

Be nice to your colleagues (seniors, nurses and paramedical staff). If you are nice and responsible, your

seniors may even tell you when there is a vacancy in the department and recommend you to their boss.

Nurses and paramedical staff may also evaluate you and have an impact on your employment (current

shortage of HA doctors also reduces the allocation to each unit & it increases competition to enter some

units). If you gain their trust, you will have a better overnight call and some may even treat you to some

night food. Internship is the time when you can meet as many people as possible whom you will later

become friends with. Some people also met their first girlfriends/boyfriends during their internship. :)

Fallacy: The intern works the longest hours and working hours decrease with increasing seniority

Fact:The above statement is true 20 years ago. Many senior staff now work longer hours than interns.

Interns and trainees are protected and the unfinished work are done by their seniors, who.(read above)

Fallacy: Interns salary is the lowest and the consultants, the highest

Fact:But the value of the salary of the intern is higher - the satisfaction of being financially independent

the first time and the opportunity to give money to your previous care-giver (or money-giver: parents, no

matter how rich they already are). You can do a survey on consultants to see how much happiness they

derive from their monthly salary. It's not comparable.

Fallacy: Interns are least like doctors as they are young and inexperienced

Fact: Interns have the longest contact time with patients and relatives (if they stay in the ward especially

through visiting hours). They have the most chance to develop and enjoy the doctor-patient-family

relationship. Patients usually pay a high respect to you when they see you working day and night as they

feel that youre overworked. Patient and their relatives cant really distinguish interns from MO. It all

depends on how you interact with patients and their relatives. As an intern, you always get the most time

obtaining history from patients or explaining to them their conditions. An intern can spend much more timetalking to patients than MO or nurses. Patients will be very grateful if you can spend a bit of time talking to

them. Also, interns sometimes pick up diagnoses missed by MOs: because you stay the longest time with

patients!

Internship is not a tough time to bear with (though bearing with toughness is also good training). It is

your intensive training course to master the basic clinical skills and experience. It is also your ultimate EQ

test for conversion from a non-viable to a viable doctor. Depending on your subsequent specialty, you may

not have a chance to practice some of these skills again and it may`` be all you have to rely on for the rest

of your career.

Welcome to internship! Do cherish your time as an intern!


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Appendix 2 Common Psychiatric ComplaintsDepression or not? Is loss of appetite plus insomnia/lethargy equivalent to depression? It is

common to have both symptoms in medical ward due to pain, sepsis, SOB. etc. Look for the

following more specific clinical clues: (i) suicidal idea (ii) negative thought: idea of uselessness,

hopelessness and worthlessness (iii) presence of recent psychosocial stressors (iv) insidious ratherthan acute onset

Is the pain psychogenic? - What should we do when paracetamol, tramadol and common

analgesics fail? (a) try to rule out any organic causes (b) more suspicious of psychiatric cause if (i)

the pain is at more than one place and of more than one variety (ii) the patient is more interested

in whether the doctors accept his/her pain than curing the pain (iii) presence of interpersonal

problems How to tackle (this is what the psychiatrist may advise if Dx is made) (i) reassure

empathetically (ii) set firm rule which everyone agree (very importantly, including the nurses, who

do not call you and your colleagues at midnight for prescribing analgesics); extra dose/tramadol

would only be prescribed after specialist consultation (iii) use non-pharmacological methods such

as water pad or ice pad when waiting for the next dose of analgesics, involve the physiotherapistand occupational therapist. (iv) if methadone user, check with methadone clinic for usual dose and

last use. **Dont be frustrated when you hear the patient say You cannot help me. He/she is

expressing his/her hopelessness and not blaming you. Admit your limitations and tell him/her you

are working with him/her to find ways to improve the condition.

EXAMS

Appendix 3 MRCPexam There are 3 parts. Part I is best out of 5 MCQ (~100Q, 2 papers, each 3hours), Part IIa is also best out of 5 MCQ (~100Q, 3 papers separate on 2 days, each 3 hours). Part I

can involve preclinical stuffs and Part IIa are more about practical things. Part IIb is PACES. There

are usually 2 exam sessions a year for Part I. One in September and one in January. Its probably

too rush to aim for September, as the online MCQ bank consists of over 3000 questions. To start

preparation in 4th

internship rotation is probably inhuman.

Appendix 4: MRCSexam The new membership examination of HK Intercollegiate Board ofSurgical Colleges (colloquially known as MRCS) is in 3 parts. Part 1 & 2 are MCQs while Part 3 is

now OSCE instead of Viva in the past. Subspecialty knowledge (esp orthopaedics) would also be

tested in all 3 parts (esp Parts 2 & 3) & it would be helpful to have orthopedics rotation in intern /

BST before you attend the examination. Part 1 is MCQs on basic science. There are already quite a

number of revision guides and mock exam papers available. Part 2 MCQs mainly focus on clinical

scenario and management plan. So not surprisingly, some of us found that its easier to pass Part 2

than Part 1 (as our basic science knowledge from Med 1& 2 was remote). Part 3 is now OSCE with

similar format as our final MB, consisting of 18 bays with 4 content areas viz: (i)Clinical and

procedural skill: clinical exam same as final MB, describe/demo procedures like central line

insertion (ii)Anatomy and surgical pathology: point out several parts on the specimen (iii)Applied

surgical science and critical care: Q&A on a scenario: (iv)Communication skill: includes stations on

(a) history taking (b) obtaining consent (c) communication with senior. The examiners need to

follow a set of questions with model answers, and you need to hit the scores of the model answer.


10/16

Appendix 5: Becoming a SurgeonLife as a junior surgeonis tough and busy. Early morning round, dealing with resuscitation/

emergency, OPD & ward duties and to acquire surgical techniques. He/she expects a busy routine

and need be responsible and hardworking. Although the young trainee is very keen to have

opportunity to learn surgery in the OT, he/she should realize that a surgeon not only works in the

OT, preoperative assessment, judgment to decide when to operate and when not to operate,

postoperative care and follow up are important parts of surgery. The opportunity to operate would

come stepwise and in the first 1-2 years theres an important commitment to ward, OPD, and on

call duties: admitting 20 40 cases in each on-call day, with on average around a quarter of whom

will deteriorate in the middle of the night requiring resuscitation or emergency endoscopy or

operation, these experiences are important in training the ability to deal with emergency situations

and optimize patients perioperatively. The role of being human retractors in the OT as a junior

trainee gives the important opportunity to learn how their seniors tie a knot, use a diathermy,

identify and cauterize the bleeder, ligate a vessel, put a stitch in place -- the basis to become a

great surgeon. How much you pay your attention to these details will show up when one day you

are provided an opportunity to do your operation. Life of a surgeon is "first become a good

assistant then perform on your own and finally, teach your assistant". Subspecialisation. The

majority of trainees have no idea what subspecialty they will finally end up in until the end of

fellowship. During BST (ie Yr1&2), the trainee has opportunity to rotate to orthopaedics or AED for

1 rotation & one of the subspecialties of NS/ CTS/ URO/ paedi surgery/ plastic / ENT for one

rotation. Being an intern is also a good opportunity to explore ones interest in these different

subspecialties, as one would need to commit to, at the end of BST, whether one would pursue

general surgery/ ortho/ AED/ NS/ CTS/ URO/ pedi surg/ plastic/ ENT. Quite a number of people

who intended to do general surgery when they were interns finally chose to work in these

subspecialties. The higher trainee in general surgery would have rotation into subspecialties

(colorectal, upper GI, Hepatobiliary, breast and thyroid), and most people will be able to make acareer choice at the end of fellowship. The teaching hospital and the peripheral hospital. Young

trainees are keen to compare with their peers in different hospitals the opportunity to operate. In

peripheral hospitals the trainee tend to have more opportunity to do surgeries like appendicectomy

& hernia repair in yr1 and become so called "independent" earlier, while trainees in teaching

hospital see more major surgeries, and have more choice regarding subspecialty training (eg all

specialties are available in the two university units and QEH; many a time, subspecialty is of small

scale in peripheral hospitals though there are exception e.g. NS in TMH). In the long run, at the

stage of becoming fellows, the surgical skills and capability of different units are pretty much the

same. In an academic unit, one has the privilege/ torture to participating in research/ workshop/

data entry etc. Some people appreciate the opportunity while some hate it. In PWH, manpower issufficient during on call with 2 interns on call with the MO, with good support and seniors always

ready to help and teach, E cases admission are much less than peripheral hospitals (average 10-20

per call day), because admission would stop when the ward is full except R room cases. In

considering the surgical career, don't just look at the situation at the trainees stage but also look

at the young fellow/ associate consultant and consultant/ Professors. Think of what you want to

become in the future, what your consultant is capable of doing, is what you can do in the

future. Work/Life balanceis generally difficult for surgical trainees due to the heavy duties and

probably you will have only limited time to spare with your partner. One should develop some kind

of interest, gather with your old friends, meet some new friends.

SURGERY


11/16

Appendix 6 Is Emergency Medicine my cup of tea? Currently, theres a severe shortage ofdoctors at AED, almost crippling the medical service. Lets look at some characteristics of this

specialty to see if it may be your cup of tea. Its also worth us all understanding more about the

AED doctor who interacts with us quite a lot, though often indirectly.

Shifts: Each shift comprises 8 to 10 hours, overall working hours are limited to 48 hours per week

(ie average 7 hours a day, around 6 to 9 days off per month). Downside: it is social unfriendly as it

is difficult for you to date friends in other specialties or in other industry who are having day off on

weekend, may affect family life. You still need to work night shift after you are promoted, while

your counterpart friends at same grade can have off-site call at home. Upside: Since you dont

overwork, there are quite a large amount of free time. You could also make up a few consecutive

days off by swapping without requesting Annual Leave. Thus the AED doctor can execute

extracurricular activities and develop personal interest during normal working hours on weekdays,

e.g., taking a course, dealing with the stock market, learning to play saxophone. You may go to the

Ocean Park on weekdays when there are fewer visitors.

Short-term Doctor-Patient Relationship Downside: It is difficult for you to follow up the progress

of the patient, and the thank you card is more likely to go to the ward case MO rather than to you.

Upside: On the other hand, with the high turnover rate in the AED, you can learn a lot of clinical

medicine in a short period of time, if you maintain a mindset of try to learn something new every

day, and keep a note of patients with interesting or unusual problems and check them out later.

Facing uncertainty Unlike the admitted patients, AED patients had not undergone prior screening

& have a broader spectrum of presentations, the diagnosis may not be obvious. Eg a man

presenting with a few minutes of chest pain with no obvious ECG or CXR abnormality but was too

worried to go home; Eg an elderly lady who cannot bear weight after a slip & fall, but no fracture.

These scenarios with uncertainty of Dx is a stress, but its also stimulating, and your skill anddiagnostic accuracy would improve with time.

Career prospects Candidates sit for Primary and Intermediate Examination in Emergency Medicine

(PEEM and IEEM) as their entry and intermediate examination, respectively; while attaining a pass

in Membership Examination of the Hong Kong Intercollegiate Board of Surgical Colleges (HKICBSC),

or colloquially known as MRCS, is equivalent to having passed the intermediate examination in

emergency medicine.

1. AED nowadays does not simply function as a triage station and an admission department like

what it had been in the old days. There are a spectrum of subspecialties one may practice

inside this field, including but not limited to: trauma service, diagnostic ultrasound, sports

medicine, toxicology, disaster and administrative medicine, hyperbaric oxygen medicine etc.2. The private market is developing for AED as they need resident service to cater for ward

complaints until the attending physician arrives, and to operate overnight clinics.

3. One may become the part time consultant for Fire Services Department or voluntary flying

medical officer for Government Flying Service.

4. Doctors in AED often has to negotiate and liaise with other clinical departments for better

collaboration of service and guideline development. This sets a path for rising in the

administrative ladder. The current HCEs in PYNEH, CPH, YCH and NDH are Fellows of

Emergency Medicine.

EMERGENCY MEDICINE


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Appendix 7 Introduction to Psychiatry

Personality/abilities/qualities suited for psychiatry)1)Good temper (2) Psychological healthiness

& confidence: sometimes, we would be challenged by patients and relatives to the point of losing

our temper; a good confidence improve our ability to control our temper, whilst a man with fragile

ego tends to be sensitive and easily display anger. (3) Good interpersonal relationship: able to

establish and maintain relationships. (4) open minded and can appreciate others difficulties, and

resolve conflicts (that's why sometimes we are consulted as "communication ambassador" when

other doctors irritate the patient or relatives) (5) being non-judgmental to others (have seen

doctors with high moral standard and they have difficulty in accepting others' dark side).

Professional life of a psychiatrist cf internal medicine& other specialties

(1) Psychiatry maybe the most mentally draining specialty!

(2) May not have more free time than other specialties, in contrast to common belief.

(3). Great freedom in choosing treatment modalities.

(4). High satisfaction due to more intense relationship with patients compared to most otherspecialties.

(5) Maybe more frustrating when patients die due to the same reason in point 4.

ExamsPart 1: written exam, most of us pass in one attempt. Part 2: clinical exam, passing rate is

about 40%.

Appendix 8 Introduction to Anaesthesia & Intensive Care

Nature of work and qualities required for the specialistSome people think that anaesthetists neednot talk to patients and mask their face all the time & tube the patient. This is far from being true.

Two important qualities are: (1) able to stay calm and decisive in time of emergency and messy

situations: in emergency operations or ICU settings patients are unstable & can make you feel that

you and the patient are going to die if you can't do so and so. (2) Good communication skills.

Patients in the ICU are not always in comatose state, in fact, the doctor will wake the patient up if

they tolerate, so still need to talk! ICU specialist deals with very sick or dying patients, and also

need to reject ICU admissions, thus need to handle the family, even consultants find this difficult

sometimes. Youll do a lot of hands on procedures that you can see the result immediately.

Exams. Part I exam is usually taken at end of Yr2/early Yr3. Basically pharmacology + physiology,

lots of bookwork, almost have to study everyday in Yr2, but people still make it. Part II: usuallytaken at Yr5. It is clinical including physical exam.

PSYCHIATRY

ANAESTHESIA & INTENSIVE CARE


13/16

Appendix 9 Introduction toOphthalmology Nature of work: mainly ambulatory, out-patient based, you see a variety of patients ranging from children to healthy working adults to

elderly with a spectrum of diseases - trauma to refractive errors to cataracts etc.

Attractions: The surgical aspect of this specialty provides very rewarding job satisfaction, especially

with cataract surgery which provides immediate visual & QoL improvement to patients. Theresalso lots of volunteering/ humanitarian related opportunities

Limitations: Even though ophthalmology is considered a surgical specialty, a large proportion of

your time will be spent in clinics seeing up to 40 patients/ doctor/ session.

Typical work hours: 9-5 pm. 4 calls/ month, usually uneventful. Some centres have off site calls eg

CMC, QMH, TWEH.

Centres PWH, HKEH, UCH, TMH, TWEH, CMC, QMH

Contents of Basic surgical training: General exposure to all ophthalmological subspecialties,

acquire basic diagnostic skills eg use of slit lamp/ indirect ophthalmoscope/ ultrasound etc, acquire

surgical skills eg cataract/ lid/ pterygium operation with wet lab training in most centres before

operation on real patientsContents of Higher surgical training(after obtaining membership of College of Ophthalmologists):

subspecialty training (paediatrics, plastic, retina, cornea, glaucoma, neuro) in your desired field, -

Phacoemulsification cataract surgery training

Exams:Membership exam at Yr 2 residency: Part A: optics, physiology, anatomy of eye. Part B:

clinical. Fellowship exam at year 5 -6 residency

Application Send in applications early eg around December each year as interviews are generally

held in late Jan Feb.

Qualities looked for in applicants: demonstrates passion in ophthalmology (attachments and prior

research is a bonus), Good academic standing, Good interview skills, Sense of responsibility and

ability to work in a team (reputation during internship is very important), Some centres will test on

microsurgical skills and check visual acuity

OPHTHALMOLOGY


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Appendix 10 Common urgent complaints

Resuscitation - you are expected to leave whatever you are doing at that moment andengage in the CPR. In case youre already in another resuscitation, politely say to the nurse

that you are so and let MO decide which side you should attend to.

Low BP: When informed of low BP on the phone, always assume the patient to be in shockuntil proven otherwise. Ask for brief history, the magnitude of BP drop and the general well

being, order an ECG while you are going to see the patient ASAP. Do not blindly give gelofusin

FR before assessment.

Possible exception to the urgency can be that the patient is already known to be in shock,

already on IVF resuscitation / inotropes and nurse inform you of low BP. Then it is acceptable

to phone order further IVF or titrate up inotropes first. But it is still good practice to assess the

patient later.

On arrival, determine whether the patient is in shock or not. Shock is characterized by tissue

hypoperfusion. Look for evidence of that in the brain (confusion), periphery (cold extremities,

prolonged capillary refill), kidney (oliguria). Often there will be tachycardia as well. Be extra

cautious in young patients. They have good physiological reserve so they can be alert and up

and about even in septic shock, but when the illness overwhelm their compensatory

mechanism the deterioration would be drastic. If in doubt always inform your MO of the case.

The next step is to look for the cause of shock. Think of the major categories of shock:

cardiogenic, hypovolemic, septic and anaphalactic. Most of the time the cause is apparentfrom the history. Heighten your alert if the patient has just underwent surgery / any

procedure as there will be serious consequence if a post procedural complication is missed.

Listen to chest and heart, palpate the abdomen, look for calves swelling, do PR exam if the

patient is uncommunicable and document all these well. Order CXR, ECG, CBC, RLFT, Cardiac

Enzymes, ABG. If patient is not in cardiogenic shock then it is acceptable to give Gelofusin FR

x 1 for fluid challenge. MO must be informed for a case of shock.

Desaturation / SOB: It is acceptable to phone order 2L O2 to a previously well patient, butanything above 6L or 50% O2 warrant attention and assessment. Over the phone you may ask

the nurse to arrange urgent CXR and say you shall issue order form when you arrive. Commoncauses of acute desaturation are: APO, Pneumothorax, AECOPD, Aspiration Pneumonia; PE is

uncommon but need to think of if no apparent cause is found (especially in cases that with a

clear and non hyperinflated CXR that almost has ruled out the above 4 causes). Check vitals

first and determine if the patient needs resuscitation. Then listen to chest for symmetrical air

entry, look for basal crep and wheezing, auscultate for murmur, check for soft calves and

edema. Again Order CXR, ECG, CBC, RLFT, Cardiac Enzymes, ABG. MO must be informed for a

case acute desaturation.


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Oliguria: Ask for baseline Cr to determine if the patient is already in chronic renal failure.Then ask if bladder scan has been done if not on foley. If not then order one to monitor urine

output. Oliguria can be a sign of shock so follow the management plan as stated above. Also

think of renal and post renal causes. Order KUB, Urine multistix and C/ST, CBC, RLFT, CaPO4,

VBG. Again don't blindly give IVF challenge until cardiogenic shock is ruled out.

Decrease in GCS: If a nurse is worried about the patient, most of the time he/she is correctas nurses know the patient far better than you. Assess GCS yourself and document the E,V,M

component. Check for pupil sizes, check for reflexes. Check heart, lung and abdomen. Order

CT brain, CXR, ECG, CBC, RLFT, Cardiac Enzymes, ABG. Watch out for CO2 nacrcosis in

respiratory cases or if patient has history of small airway disease. Inform MO in case of acute

drop in GCS or GCS < 8 as patient may need airway protection.

Convulsion: Attend the case just like you would in case of resuscitation. Put the patient in

recovery position, order 100% O2 mask. Follow the instruction in houseman handbook forValium and then Dilantin. ALWAYS REMEMBER TO CHECK H'STIX.

Chest pain: Ask if vitals are stable. Order ECG over the phone. Attend early if the pain issevere. Do heart and lung exam, check the calves and look for edema. Order CXR, ECG,

Cardiac Enzymes. If patient has history of ACS and BP are stable then may try TNG. If the

patient looks unwell and ECG looks normal, think of aortic dissection and PE. Inform MO.

Abdominal pain: Ask if vitals are stable. Check for all quadrants for tenderness. Inform MOif there are signs of peritonism. Ask for the last time of BO and consider give Fleet enema if

constipated. Order AXR, CBC, RLFT, CaPO4, VBG, Amylase. If abdo pain is severe, Alwaysconsider ischemic bowel.

Hypoglycemia: Withhold all DM med and insulin. H'stix Between 3.5 - 4 and asymptomaticoral feeding patient can be managed simply with orange juice. Below 3.5 or symptomatic

patient you may give D50 40ml IV, followed by a D5 drip.

Hyperglycemia:If H'stix is below 16 you may give stat dose Actrapid HM 6 unit SC. Avoidgiving stat dose insulin after nocte time as you may induce hypoglycemia. For H'stix above 16

then consider the possibility of DKA / HHS. Ask for previous H'stix readings. Order urine

ketone over the phone, check blood for VBG, CBC, RLFT, Osmolality. Look at the HbA1c cangive you some idea whether the hyperglycemia is acute or not.

Hyperkalemia: For K below 5.5 you may order Resonium C 15g Q4H x 3 PO / PR. If K isabove 5.5 or patient with sinus bradycardia, then order ECG to look for hyperK changes, Give

Resonium C, DI drip and Calcium gluconate.

Hypokalemia: Can be managed with Syrup 2g Q2H x 1 - 3 depends on the severity. Ifpatient cannot tolerate diet then you may consider giving IVF with 20mmol KCl / pint Q6 - 8H.

Be very conservative in giving K Supplement in ESRF cases. DO NOT GIVE K SUPPLEMENT FOR

POST HEMODIALYSIS CASE.


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Hyponatremia: Usually no urgent intervention is needed if Na above 125. If below then it isnecessary to check the patient's fluid status. Manage according to houseman handbook. Do

not give NS unless the patient is dehydrated. Do not give NaCl if patient is fluid overloaded.

Save urine for osmolality and Na, together with blood osmolality, RFT and TFT. For severe

hyponatremia order RFT Q8H to make sure you don't overcorrect Na too fast.

Certify Death: This should be the next item you do after resuscitation and handling urgentcomplaints. While it is a courtesy to the deceased one to promptly certify the case, there is

another practical reason for prompt action: uncommonly the case may be referred to coroner

either for uncertain cause of death, or simply because of the patient is under guardianship

order or mental health ordinance. The coroner is very conscious about the time of death. You

may have to explain to the court if there is big discrepancy between the time of asystole /

terminated CPR and time of certified death.

It is a good habit to remove all ECG stickers and tidy up (at least slightly) the patient's cover

sheet before letting their family in esp after a resustication: this is a simple gesture to show

your respect to patients, and family members usually feel better when they see patient

covered up neatly instead of a mess after your final examination on him/her.

Disclaimer: This is not an official document. This is personal sharing on a friend-to-friend basis, amentoring activity.

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Survival Guide for Medical Internship

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