LME 2021 Reflection Rambles (III)

Before moving to my next placement, some final thoughts to make sense (or rather, attempt to) of it all.

As I stare down as my none-too-clean cup with remnants of chrysanthemum petal, its green colour (it was originally yellow - I hadn’t washed it too well for 2 days) immediately reminded of the consultant’s comment on a baby’s stoma output (or was it aspirate) which had turned green as well ‘cos of oxidation’. Promptly washed my cup thereafter.

Surgical elective has whizzed by! Here is the breakdown of the good, the bad, and some sense of camaraderie with Bubbles (scroll down and you'll see why!)

Overall experience: 100 stars

Gorgeous sunlight and shadows on a sunny day at the Atrium

The Good:

  • Holistic and breadth of experience: on-call (making rounds to PICU, ED – appendicitis is truly common; clerked the patient myself), grand rounds (virtual), multi-disciplinary input (actually in action as exemplified by the cloacal baby), ward rounds, close partnership with the acute care/anaesthetists/nurses

  • Scrubbing in (and actually doing something): the fact is, children (and especially neonates) are pretty small. And with two surgeons already it is rare that the medical student needs to scrub at all but when I actually did – let’s say the teaching and learning was stellar! But what made it that good was the pre-op work done: going through the theory, visualising the procedure etc

  • Theatre: gensurg and more! Not to mention some bonus ENT and urology as well because elective list for gen surg was not running

  • Valuable teaching (100% respect for them)

  • Tertiary centre: things get done (quicker)

The not-so-good:

  • Elective list not running: there were one or two rather slow afternoons

  • Changing consultants: good and bad I guess! Some involved medical students more

  • Slightly less hands-on but inevitable given the high-stakes nature of the specialty: pyloric stenosis ‘olive’ but the child was unsettled (VERY), difficult cannulas (vein visualisers exist! But oh, it is broken (classic))

To make sense of it all, two main things:

Firstly, paediatric surgery as a career. For someone who chose this elective to definitely rule out surgery and to reaffirm paediatrics, whilst reaffirmation of paeds has ticked, the first bit of ruling out surgery has not. Having enjoyed this placement immensely and seeing the value and role of the paediatric surgeon – this has effectively derailed my 5 years of MBBS conviction of doing Medicine. It is not an easy decision to make, and one that I seem to have a (nearly) quarter life crisis on and by no means, it can be one made within a few weeks of experience. Paediatric surgery is one of the most competitive surgical specialties (2nd place with 8:1 ratio in recent years) and its training pathway requires immense sacrifices. More information here: How does one address this conflict? Step 1: (BUBBLES below) Step 2: Research about the specialty, reflect on conversations with the paed surgeons and my own experience (Cue learning theories of reflective practice and transformative learning, more on that later) Step 3: Do what I can portfolio-wise and also appreciate my past self in covering the bases by going for surgical courses + writing Step 4: Re-evaluate at appropriate time stamps. It may be a phase or it may have to be an active decision to forgo on balance of work/life/competing interests, but it is one that would perhaps be clarified once F1 starts.

Secondly, teaching and learning principles

How does one integrate theory into practice? How does one address the technical craft along with the multitude of technical and non-technical skills required? Bearing in mind, all of this in the perspective of the adult learner (social context, learning based on choice, ability to reflect). Whilst numerous theories exist, it was difficult to pinpoint one exact one – they definitely overlap. Nevertheless, I did extract some principles: stepwise learning leads to global proficiency with good supervision ensuring patient and trainee satisfaction; self-directed learning (meta-thinking? Self-assessment of needs) can provide a basis for experiential and transformative learning (i.e. what do you already know? How does it fit and interpret new information based on our own understanding to date? For instance, during the teaching round (overt aim of helping prepare the reg for his exam but ended up involving the entire entourage of 7) we were encouraged to voice our deductions (best be prepared or bear the wrath of a non-too impressed consultant), and through this discourse, arrived at a sensible outcome. Learning in communities of practice also overlapped with situated learning – this elective has allowed me to appreciate ‘the way it is done’ and the ‘hidden curriculum’ in medical practice e.g. dynamics between the team and patients. (side note: the surgical stereotypical ward round was overturned but side note 2: no need for stethoscopes most times lol which was a welcome relief given the two masks I already had on hand/neck/face). For instance, consent-taking and explaining that to anxious parents is an important skill! Furthermore, discourse about post-op complication and especially addressing iatrogenic harm (remember the through and through bladder perforation after lap appendicectomy?) are important to allow juniors to appreciate the professional working environment (and its inevitable challenges)

Moving forwards, I would like that in my own career training pathway that I am given clear directions as to what the standards and objectives are, and that I am suitably challenged yet supported, but always learning in a safe motivating environment! Work-life balance? Yes please. As well as work-work balance.

Rashid, P. (2017). Surgical education and adult learning: Integrating theory into practice. F1000research, 6, 143. doi: 10.12688/f1000research.10870.1

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