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.

The placement continues

I am firmly of the belief that if you don't have anything nice to say, then it's as well to keep quiet. That is the main reason why there has been silence in my blogspace for a week - it was a bad week, a hellish week, one that I think might rank as one of my worst weeks ever. Today I am feeling more positive, so I am taking the opportunity to squeeze out a blog post before everything goes wrong again, as it quite possibly will.

I continued with stroke and diabetes last week, and this week there will be more of the same. I am feeling more confident with individual consultations in outpatient and GP clinics, which are generally about weight reduction or type 2 diabetes (or both), although I saw someone this morning (was it only this morning?) with Irritable Bowel Syndrome. I have just 21 more working days before this placement is at an end, and I am confident that I will reach the finishing line, although there may not be much blogging activity until May begins.

I have spent some time revising the BDA Conference abstract according to the suggestions provided, have sent it back to them so they can decide whether I need to produce a poster or an oral presentation. I spent Saturday working on that, and then on Sunday I worked on a presentation that I delivered today about a journal article describing a study to determine whether people in hospital who have many illnesses are more likely to have barriers to their access to food at mealtimes. I produced an uninspiring performance talking about an uninspiring article, but at this stage I don't care as long as the relevant Assessment Tool is signed off to say that I did it and it wasn't a disaster.

Job applications have had to wait. I received some useful feedback from one of the jobs I applied for - they are looking for a qualified dietitian rather than waiting for me to qualify (which won't be before July), but suggested a couple of things for future applications. I'll get back to that later, because with the workload from here onwards it will be tough to find the time that a good job application needs. It was a good idea to get a couple out, though, and will definitely make future applications easier.

Placement dietetic experience

There really has been a lot of stuff happening. I thought that coming to an unfamiliar town and living in someone else's house would mean I had a load of free time - that's what happened last time. In fact, because of what happened last time I made a lot more effort to find a good place to live, and have now signed up to play at two badminton clubs. This has resulted in me enjoying my evenings immensely, but having no spare time for homework or blogging at all. And there is homework that I should be doing, at this very moment.

It's been a while since I ventured into the territory of describing the actual dietetics I've been doing, what with having had a bit of a breakdown in weeks 3 and 4, but things are really much better now at the end of week 6. Half way.

I have now seen an adult with a BMI of 9.4 and a weight of less than 4 stone (56 lb, 25 kg), and someone weighing more than 24 stone (335 lb, 150 kg). A patient with kidney failure kindly allowed me to feel the 'bruit' or 'thrill' from their newly constructed arteriovenous fistula that will be used to facilitate haemodialysis. I observed a cooking session carried out by one of the Food Educators, where parents and their young children cook something that they can then cook again at home. Cooking used to be taught in schools when I was young, but now this seems to be one of the only ways that people can gain the skills that I took for granted. If you've never tasted a courgette or chopped an onion, for example, you're not going to buy them for your family.

I have to admit that the GNT dialect is giving me a few food-related difficulties. Bread rolls/baps are called bread cakes (in Manchester they were barm cakes), which is straightforward enough, but it gets more complicated with meals. The main meal is dinner, and is eaten at dinner time, which is often in the middle of the day, except when dinner is eaten at tea time. Tea time is in the evening. Here is a direct quote from a patient that I wrote down: "We eat our dinner at dinner time, not tea time." One patient didn't seem to understand when I was talking about lunchtime, and I had to explain that I meant the middle of the day. Supper often means a snack taken after tea, i.e. before bedtime. 'While' is used in place of 'until', e.g. "I work 8 while 5 during the week." Now all that is sorted out, I can usually understand what they're all talking about.

During the past week I have been on stroke and diabetes, with an outpatient clinic or two thrown in for luck. I like stroke and diabetes, particularly diabetes, which I find fascinating in a very nerdy way. All those lovely numbers! Blood glucose readings, HbA1c numbers, cholesterol and triglycerides, blood pressure, BMI, waist circumference, carbohydrate portions and units of insulin. Then there's Oral Hypoglycaemic Agents, different types of insulin, meters, pumps, lancets, strips and a team of doctors, specialist nurses, dietitians, pharmacists, podiatrists and opticians. I observed a fairly complex set of patient consultations, did a couple of fairly straightforward ones myself, and almost felt like a real dietitian for some of the time.

The feedback I'm getting is good, and apart from the backlog of homework, I think it's going well. There's also a bit of exciting news from the world of University - my supervisor persuaded me to submit an abstract of my research project, on visual impairment and food choices, to the annual British Dietetic Association Conference. This week I found out that they have accepted it for presentation (with modifications). This is good news for my CV, but bad news for my workload - now I have to make the modifications and re-submit the abstract. I will only find out nearer the time whether they want an oral presentation or a poster, and then I will have to create that. My placement supervisor also suggested that I could practise by presenting the paper to the department. Oh boy.

So I have plenty to be getting on with, but the priority has to be a job application this weekend, and then I must sort out my placement portfolio. I should mention that it was nice to see Mr A again, and I managed to recognise him despite his long hair. That was another job for me this weekend!

What I've been reading

Mansfield Park
by Jane Austen

"The novel's heroine, Fanny Price, is a 'poor relation' living with the Bertrams, acutely conscious of her inferior status and yet daring to love their son Edmund—but from afar. However, with five marriageable young people on the premises, the peace at Mansfield cannot last. Courtships, entertainments and intrigues throw the place into turmoil, and Fanny finds herself unwillingly competing with a dazzlingly witty and lovely rival."

I'd say this isn't one of her best books, and I actually found it quite difficult to read. The language seemed to take my attention away from the story, which wasn't gripping enough to keep me engaged. The heroine is also quite a drippy character, always needing to sit down for a rest or being too overcome to speak. The story unfolds really slowly, and then all the concluding action is packed into one or two chapters at the end, by which time I'd lost all sympathy with Fanny, and wouldn't have minded if she did live out her life as an unhappy spinster.



Memoirs of a Geisha
by Arthur Goulden

"The book tells the extraordinary tale of a geisha, summoning up a quarter century, from 1929 to the post-war years of Japan's dramatic history, and opening a window onto a half-hidden world of eroticism and enchantment, exploitation and degradation."

Although I didn't remember it beforehand, I have actually read this before, and thought then it was a true story, rather than being based on a whole load of research. Well-written certainly, and much easier to read than Jane Austen. But I feel uncomfortable not knowing what is true and what is author's imagination. Despite all the research he might have made stuff up. So it's a good read but I remain wary of the contents.



The Queen's Fool
by Phillipa Gregory

"It is 1553, Henry VIII is dead and his young son Edward is now king. 14-year-old Hannah Green, a determined Jewish girl with the gift of foresight, has come to England with her bookseller father to escape the Inquisition in Spain. After a chance meeting with the dashing Lord Robert Dudley at her father's bookshop, Hannah finds a new life as a court fool - and a spy. Reporting to Dudley all that happens around the sickly king, Hannah is also sent to spy on Princess Mary, with whom she strikes up a loyal and lasting friendship."

I've been toying with the idea of Phillipa Gregory in audio book form, but Landlady Lola has several in print so I've taken advantage. It's interesting, a story woven around real events and personalities, and while I have no idea of the level of historical accuracy, I don't really care. And MUCH easier to read than Wolf Hall.

The last two weekends

The week of low self esteem the week before last was followed by a family weekend. I went home on Friday night and Mr A and I became reacquainted - I recognised him straight away, and I think he knew who I was, even though he denied it. I reminded him that I'm the one who used to do most of the laundry. Then we went to the pub. He says that without me there, the house is rather quiet, mysteriously messy, and his clean clothes don't magically appear on the kitchen chair. We had a lovely evening, but all too soon I was away down south to visit mum and dad and meet up with Lola II.

Lola II has been reading me books at bedtime whenever we're in the same location. We started with 'My Friend Mr Leakey', and we're now coming to the end of 'The Phantom Tollbooth', and were wondering what to read next. Lola II had forgotten to bring a book with her this time, so I chose a book of Fairy Tales by Hans Christian Andersen from the bookcase, and asked for the last story, which happened to be called 'Booby Hans'. Booby Hans follows his brothers to see if the princess will marry him, and brings her presents that he found on the way: a dead crow, an old shoe and some mud. I think it's the translation that made it so funny. It's definitely going to be our next bedtime book.

Then this weekend I was off to Sheffield and meeting Lola II and sister D on one of their rare journeys into the North. On Saturday we experienced a large number of policemen, which was unexpected but could have been anticipated, because the Liberal Democrats were having a Spring Conference. We caught a tiny bit of a demo from a distance, but the police were far more prominent than any rabble.

In brief, we went on a geological walk in the city centre looking at different rocks that have been used for paving, shop fronts, benches and decorative stuff, visited a shop that sells amazing hot chocolate four times, ate Japanese, Korean and Moroccan food, saw a film, went to a museum with a Sports Science exhibition and an Art Gallery whose cafe was closed, spent a short time in the botanical gardens and the Winter Garden. It only rained on Sunday morning. The Bed and Breakfast where we stayed was astonishingly good and thoroughly recommended, and we all had a lovely time.

Back at work now, and I'm going to be doing stroke and diabetes for the next three weeks, which I am looking forward to a great deal more than what I have done so far. I have a lot of things I ought to be catching up with at home, but instead I have been to badminton this evening and will do the same tomorrow, and may even go out on Thursday as well. It's slightly frustrating that I am not devoting much time to blogging, but I'm sure I'll get back to it when time allows - I still have lots to say!

It gets better

Here I am again. It's been too long, hasn't it? But my days are full at the moment, especially as I've been applying for jobs. Applications take up much spare evening time, and I'm not prepared to compromise on badminton time. Last week I played on both Monday and Tuesday, and I did the same this week. I also spent quality time with Landlady Lola III, and there's homework from school. At some point I will need to spend probably more than one evening on my 'Journal Club' assignment, which is where I present an interesting article from a recent journal to members of the dietetic department. I haven't even looked at the article since I chose it in week 1.

Enough excuses, what has actually been going on? I have more than a week of work to write about, seeing as how I refused to write about it last time.

I have been doing work.

There, that just about covers it. Last week was not nice, I did not enjoy it, but it turns out I was being overly sensitive and self-critical and I was actually doing very well, rather than astonishingly badly. Who'd have thought?

The sort of work I was doing involved watching other people doing dietitian-type activities and wondering how on earth I could possibly presume to offer dietetic advice to sick people. I had a go a couple of times, but I thought I was a bit rubbish, except for the presentation I did about healthy eating to a group of five patients with lung disease and three of their relatives. I like giving presentations and I'm good at them, so it was very demoralising to think that I was being criticised. Except it turns out that I wasn't. Really, this work experience lark is very confusing.

So it has been much better so far this week, although I am still having to spend time in different hospitals all the time. On Monday I was at one hospital, on Tuesday at an 'intermediate care' home (where they put patients who are not ill enough to be in hospital but not well enough to go home) and then a GP clinic, and today I was at the same hospital as Monday in the morning, and then a school in the afternoon. Tomorrow and Friday I'm at two more different hospitals before the dreaded 'Reflection' on Friday. And then a weekend with Lola II and sister D. I'm hoping for some adventures!