Street Party

At last, I've finished. It's over. I no longer have to subject myself to daily scrutiny, open my soul to self-examination, confess to my sins in public, tell untruths and half-truths - "Are you enjoying yourself?" "What aspects of your practice need improving?" "What aspects of your behaviour do not meet our standards?" "Have you enjoyed yourself?"Of course not. It's been horrible.

The worst of it is that being a good dietitian is very difficult indeed. It requires extremely complex messages to be communicated clearly, in a limited time, with a healthcare responsibility on top. Of course, the consequences of being a bad dietitian do not compare with those of being a bad surgeon or a bad fireman. But I take what I do seriously, and I want to succeed by my own standards. The last three months have made me think at times that either I can't achieve this, or that I no longer want to. I'm fairly sure that this feeling will wear off, but it's a horrible thing to imagine that four years of study are leading towards a career that won't suit me after all.

I'm still waking up thinking about patients and consultations. Could I have done that better? Should I have suggested something else? Did I really listen to what the patient was saying? I'm sure it will get better. I hope so.

Meanwhile, we had our street party to look forward to, in honour of the Royal Wedding. Mr A hadn't taken an active part in the arrangements, but had cooked enough for 10 people. We have enough for 8 left over. It was a great opportunity to meet more people from the surrounding streets, and the weather was fine, so that's what we did.

It took a good deal of effort, given that neither Mr A nor I are particularly comfortable striking up conversations with strangers, but we managed. I met someone who is an A&E doctor for three days a week, a GP for two days a week, and at weekends he is the chief medical officer for Formula 2 motor racing. He also has a baby less than a year old - and he had time to come to a street party. We also met the neighbours of the chap who organised the whole thing, and who are ardent Republicans, and felt the need to make this clear at every opportunity.

Now I have an extensive list of the things that have been neglected for three months, and things that need to be sorted for the next month: for the Conference and leading up to my final exams. I have made a first attempt at my Poster, and need to get that sorted as soon as possible so that it can be printed in time. But first - a haircut is well overdue.

Home for the long weekend

Landlady Lola and I celebrated the end of my tenancy on Wednesday, with a bottle of wine and a lovely evening, during which she showed round a potential new tenant. She's gone off on holiday now, and won't be back until after I leave. I hope we'll keep in touch. I tried to take a picture of her, but she doesn't photograph well at all (unlike the cats), and I gave up in the end.

This weekend has been a lovely reminder of life before placement. I pretty much finished all the work related to the placement before I came home, including the presentation of my case study, so I've had this four-day weekend completely free from work. Except today I might just check that everything's in order with my portfolio so I can hand it in on Tuesday.

The last few days at work were fine. The idea is that each student is given two wards and we look after all the patients who are referred from those wards. It hasn't worked out that way at all, because there just happen to be hardly any patients needing dietetic input on my wards, so I've been given any patients that happen to come through. This means an awful lot of walking and stair climbing. All good for the weight loss plan.

Coming home is less good for the weight loss plan. It hasn't been too bad this weekend, but much more difficult than in GNT when I have such restricted access to food. Luckily in the department there are no cakes or biscuits, I bring a fairly spartan packed lunch, and as a lodger I only have foods for mealtimes and nothing to snack on. When I start living back at home I may have to plan a packed lunch even though I'm not out of the house, just to stop excess intake at lunchtime. Or something. It's difficult, anyway.

Mr A has been very busy in the garden over the past few weekends, and it's looking pretty good now. He has some ambitious plans for the area behind the house that contains the log store and a paved area that continually sprouts with weeds because we think it wasn't laid with any weed-proof membrane. A pair of robins is nesting in the garage, the sun has been shining all weekend, and I've done four loads of washing so far. The main job I've been trying to do all weekend is to replace the rope on the clothes airer, which has frayed down to a thread. Perhaps today.

Almost there

I have an hour to write before my last badminton evening in GNT - both the Monday and Tuesday clubs stop after Easter. It's been pretty busy, both during the day and in the evenings and weekends, seeing patients, doing homework and catching up with Mr A, who continues to be a hero even though I'm much less fragile now.

The work on the wards is going well. The manager of the department asked me directly last week, "Are you enjoying yourself?" It was a tricky moment, and I just said "I'm having quite a good week." It's not enjoyable, I'm too wary of making mistakes. There's a well-known theory of learning, which is all about moving from 'unconscious incompetence' through 'conscious incompetence' and 'conscious competence' to 'unconscious competence'. I've reached the conscious competence stage, which is very much like becoming able to walk along a tightrope: lose concentration for a second and the effect can be serious.

The supervising dietitians in this final phase are much more encouraging and have a way of imparting advice and information that makes it very easy to take on board, unlike many other members of the department that I had to work with earlier in the placement. This isn't deliberate; the other two students worked with these same people in previous weeks, I was just unlucky. I'm fairly certain that my meltdown plus the feedback I've given will mean that the same mistakes won't occur for future students.

I've been exposed to all sorts of different conditions over the past couple of weeks. Alcoholic liver disease, pancreatic cancer, chronic obstructive pulmonary disease, an oesophageal operation to treat achalasia, and a number of old people who have been admitted for all sorts of conditions but can't be discharged until some arrangement is made to support them at home. In the hospital, the main aspects of dietetic treatment involved enriching food (with extra calories and protein), offering extra snacks, and then prescribing supplements of various different kinds. Occasionally there's someone who needs to be fed through a tube, and the other two students have both been involved in intravenous (parenteral) feeding.

I've also been seeing outpatients, and tomorrow's clinic is unlike the GP clinics I've seen over recent weeks. The referrals from GPs have almost (but not quite) exclusively been about dietary advice for people who have type 2 diabetes, are overweight, or both. The clinic tomorrow has an array of possibilities, including low folate and vitamin B, polycystic ovarian syndrome, someone who claims to be consuming more than 2500 calories a day but has managed to lose weight, and someone who is finding it difficult to manage an ileostomy. It's a bit daunting, actually. I'm fairly confident that I can manage now, though.

Meanwhile, I have completed my case study and will be doing a presentation to the department about it on Thursday. It isn't actually a very interesting case, but that hardly matters at this stage. We students have done our joint audit and our joint audit report; writing a report between four people one of whom is 50 miles away is difficult, and it has dragged on and been emailed to and fro so many times that we're all heartily sick of it.

Outside work, this week is difficult because of my hectic social life. Lovely Landlady Lola is going away on holiday next week, so tomorrow is our last night together and we will no doubt share strong drink and sing mournful songs. She has managed to resist my dietetic influences throughout our 12 weeks together and maintains her shocking diet; today's lunch as reported: a crisp sandwich (white bread, butter and a packet of cheese and onion). Meanwhile I have three types of salad in the fridge that I pack into my lovely Japanese lunchbox and take to work. This healthy lifestyle including the two lots of badminton per week has allowed me to lose 5 kg and counting. Progress on the weight loss has stalled, but I'm still determined to try and keep the weight off when I go home. There will have to be changes.

Last night was the last Monday night badminton, so I went to the pub afterwards and didn't get home until much later than usual. Tonight is the last Tuesday night badminton, and I'm very much afraid the same thing may happen. Combined with tomorrow night being the last night with Landlady Lola I'm not entirely sure how I will get through Thursday - at least that will be the end of the week, thanks to Easter. And then it's only three more days, and I can go home!

Mr A is my hero

You may be aware from various hints I have dropped that I'm not enjoying this placement very much. I don't want to say too much because a) it's boring and unpleasant to read about someone else's misery and b) I would have to describe the behaviour of various people in a negative way, which I'm not prepared to do. It's also very difficult to write about what I'm doing, because I'm extremely wary of including anything that might identify a patient.

In general then, last week the three of us students were engaged in Peer Assisted Learning, which means that in pairs, we were given a couple of patients to go and see, and we did the job together. Compared with some of the other weeks I've lived through, it really wasn't bad. This week we are in Consolidation, which means that we are given patients to see independently, reporting back to the supervising dietitians at the end of the day. This is actually going very well so far, although as ever, I'm prepared for everything to fall apart at a moment's notice. Hope for the best and expect the worst, that's me.

The weekend, however, was wonderful. Not because of the spring-like weather, which I didn't see much of because of having to work on my case study, but because of Mr A. He not only cooked wonderful food for us, toiled in the garden chopping out loads of plants that had been killed by the harsh winter, took the resulting bags of garden waste to the tip, gave me hugs on demand and listened to the endless tales of indescribable cruelty I've endured, but also took me out on Sunday to a lovely pub restaurant and suggested a very modest meal to share so I didn't eat the enormous dinner that I was inclined to choose. He also emailed me links to amusing videos of monkeys. He is wonderful, and I'm very lucky to have him.

Being patient-centred

It's been a relatively good week. I did some good consultations and some not so good, a couple without supervision and quite a lot on the stroke ward. Very little diabetes this week - just a gestational diabetes clinic. I compiled a list of low fat/low sugar yogurts, and a checklist to try and help me remember everything that needs to happen with any dietetic intervention on the ward. A patient (the patient's daughter actually) agreed to be my case study. I had quite a long meeting with the head of the department, who has given me some suggestions on how to develop the 'Activist' side of my personality, the bit that holds me back from being confident with new experiences in new situations.

One nugget of interest was a consultation at a GP clinic with a man who wanted to lose weight. The 'classic' way of running this type of consultation is to talk about the principles of healthy eating for weight loss, look specifically at the patient's diet and then agree where changes could be made. Then the patient either wants to come back, or doesn't.

I've been trying to be less directive and more 'patient-centred', so I've been giving the patient the opportunity to identify where changes could be made. In this scenario, the diet described had so many possibilities that it seemed a really good idea to let the patient choose - that way he would start with something he was probably going to be able to change, and therefore see some results and maintain motivation to continue. The choice he made was disappointing (for me) - he wanted some recipes for vegetables so that he could increase his intake of veg with main meals.

Of course, this wasn't all that we talked about, and I made it clear that increasing something without reducing something else wasn't going to result in weight loss, and we came up with a couple of other things. But when I talked it over with various other people, we decided that it was the right approach - if boring vegetables were stopping him from losing weight, then that would be a useful thing to tackle. Counter-intuitive, but perhaps correct.