Gratte-ciels, George Micheal, and GPdom...

To stop this getting too medic-y, I thought I might write about some nice things I did this weekend.



I went to the Italian supermarket in Little Italy and bought olives, fresh pasta, artichoke hearts (ridiculously cheap) and risotto rice. I even heard someone say "Wow, this is just like my Mom (note: not Moma!) used to make!"


I walked on Mont Royal (the park on the mountain) and watched the most amazing sunset overlooking the city. I saw the St Lawrence river in the background, and in the foreground, the gratte-ciels (skyscrapers) as the lights started to come on for early evening, and felt at peace with the world. Here is a photo I am rather pleased with:

I bought two T-shirts, one with a picture of Farine Five Roses on (famous old grain silo sign that still lights up even though the grain factory is long gone), the other days "Vive le bec libre" (Long live free Quebec). A bit politique, but soooo Quebec!

I went to a Halloween party and danced with sailors, cowboys, vampires and George Micheal (!). I saw a girl who came dressed as Eve, which basically meant a bikini with 'fig' leaves stuck on, get told to cover herself up with a coat as she was breaching public decency! I got told off for lacking imagination by wearing scrubs and a tourniquet on my arm (you'd be surprised how difficult that can make drinking!)....I know, I know, but it was short notice. If I go again on Wednesday (actual Halloween) I'll make more of an effort (which seems to equal 'wear less clothes' for girls here....!).

I drank coffee in a cafe with bare brick walls and a piano in a corner, and wrote my thoughts down in my notebook, on a cracked wooden table, while Latino jazz played in the background. It has been cold this weekend- so cold that when I stepped into the cafe I wondered why they had a smoke machine on (it was the heat misting up my glasses!). Winter is coming- fast. My time here is shortening, which makes me sad, but I'm trying to enjoy every minute of it.

What I haven't given too much thought to is my UK-PFO programme (this year's MTAS). I have drafted answers to the questions, but not much else. Today I looked at the programmes. The areas I was thinking of applying to don't have many programmes that include Psychiatry. I'm not definite if that's what I want to do- but I do like it a lot, and it would be good to have it if that's what I apply for my Specialist Training in. Should I apply somewhere I hadn't really considered? Or risk somewhere I know with only 3 jobs that include it? Does it even matter that much anyway, especially at F1 level?

Ideally I want a job where I can do Psychiatry, Obs and Gynae, and GUM. But suggest GP and I'll shoot you, or alternatively myself. Suicidal/homicidal ideation, as they say here. Oh dear. Somebody fetch the sedatives, and pack me off to suburbia....

Keeping Up Appearances

The Mental State Examination is an examination of the patient’s appearance, behaviour, mood, thoughts, cognition and insight. (God, this sounds like a textbook. Bear with me!) It is a way to describe what’s going on in the patient’s mind at that point, and how the patient is responding to that emotionally. The first part, appearance and behaviour, should be so clear that you could read it and immediately pick out the patient in the waiting room if you’d never even seen them before.

For example: Young Causasian (?) male, yellow skin, short yellow hair, orange T-shirt, blue shorts , poor self-care ( wearing same clothes for 10+ years), excessive psychomotor activity.

Might describe:



The other day I read one someone else had written. It said something like “30 year old female, short blonde hair, plastic glasses, unshaven legs.”

The woman in question had suffered a chronic mental illness for several years. The ‘unshaven legs’ was, apparently, a reference to her poor self-care, and, although the patient denied psychiatric symptoms, was perhaps a sign that all was not well.

We all judge on appearances all the time. It’s human nature. But it seems psychiatric patients are judged more harshly than others. If I had a friend with unshaven legs, I might think about it this way- it’s winter so she’s wearing trousers most of the time/she’s single so not bothered about anyone seeing them/she’s been busy and forgot/she thinks it conforms to a patriarchal view of what women should look like so doesn’t do it on principle/ all of the above, but uses the latter as her excuse.

But, said the writer in question, when I ask him about it later: it was written in the mental state examination, because it could be evidence of her mental state. She’s not shaving because she’s not taking her medications and is now becoming preoccupied by her hallucinations. She’s not shaving because she doesn’t want her body hair to fall into the hands of her persecutors (apparently this is quite a common reason for patients with schizophrenia not to shave). She’s not shaving because she’s suicidal and doesn’t see the point as she’s planning to kill herself next week.


At this point, I pull my skirt over my knees, so no-one can examine my own legs too closely.

Amusing Experience of the Day

Sitting in a room full of doctors, nurses and psychologists, discussing what exactly defined "an Emo" (sic).

I think our criteria should be ready in time for DSM-V (which, by the way, I bought a copy of (DSM-IV) in French today, which excited me far more than I should admit to)

A strange experience

Something rather strange happened to me today.

I had a few hours between things, and decided to go and pay my rent (it was overdue). Unfortunately I had to go across the other side of town to pay it, but fortunately I have a weekly travelcard, so thought I should go and get it out of the way

I was on my way when I had to change trains. When I reached the platform, it was packed with people. I thought this wasn't unusual- it was at the intersection of two lines (and this city only has four tube lines) and quite central. I walked down the platform.

As I stopped, I noticed some people in fluorescent jackets on the line. My first thought was they were doing engineering works. Then I noticed they were crowded around a man who lay across the tracks. Their jackets were that of police and ambulence men.

It's funny how the brain works- my first thought was maybe he had a heart attack and fell. But with slow horror I realised it wasn't possible from the way he was lying, perpendicular across the rails (and the way the metro here is laid out, it would be virtually impossible to fall onto the tracks. It would have to be a consious decision to jump.) He was unconsious. On the platforms, every person was transfixed, watching in silent horror as more policemen ran onto the scene.

The metro workers started to tell people to clear the platforms, and only reluctantly did we start to move, turning back every few seconds to confirm with dread what we thought we had seen. It was horrible. I thought I was going to cry. On leaving the station, I was in two states of mind: one verbal, logical, thinking "How will I get across town to pay my rent now?" (and I know how callous that sounds but it was really the only response I can explain), and the second I can't explain in words as it was purely emotional, but it was something like "ohmygodohmygodohmygod".

I walked to the bus stop. Everything felt like it wasn't quite there- as if I was walking on a projected image of the city. I paid my rent on autopilot and ate a hot dog. It was only when I returned to the hospital I ran into one of the doctors in the street. When I told him what happened, he was very understanding, and bought me a cake 'to raise my blood sugar'. He said something similar had happened to him and he'd felt similarly shaken afterwards. I continued my day, feeling better at least that I had talked to someone and they'd understood.

The thing is: I've talked to suicidal patients, who've told me their plans in great depth. I've talked to people who've attempted suicide and regretted surviving afterwards. I've talked to people who say that if they leave hospital, they'll do it again. It was hard but I can handle it. But seeing a body, seeing it so final (I don't know if he was hit by a train, but there are signs everywhere that the tracks are live so anyone touching the lines would probably be electrocuted....) really shook me. Why wasn't this man someone I'd see in the ER saying "I feel suicidal, please help"? Had he already been? What was his story? Why was he there? And why was I there?

And why could neither I nor anyone else turn out heads away? Is it more that just a car-crash reflex? Is it our collective guilt for witnessing someone else's tragedy too late? Is it our shocked realisation that people do this, in front of our eyes and we can't pretend it happens somewhere else far away from our comfortable lives? Is it fear that it could one day be us or someone we know? Watching this man, I felt he was someone I 'knew', in that he was as much flesh and blood as I am now, and I wanted to turn back the clock and stop it from happening.

And why can't I stop thinking about this?

L'avenir

I am in love with the country.

I love its open spaces. I love its friendliness, and the fact that people are genuinly interested in where you come from, and what you're doing here. I love its coffee. I love its awareness in the environment. I love its bilinguality and the fact that people say things like "Quebec is part of the national psyche". I love its pancakes.

I love this city because at 8pm on a Sunday night you can go into a second hand clothes shop and look at old navy uniforms and ballgowns. I love its old houses painted in bright colours. I love the fact that people greet you with "Salut, hello" to see which you respond to. I love that the streets are alive all night, and people are happy. I even love the ongoing roadworks that girls step through in their stillettos on St Laurent.

In short, I want to move here. But it's actually very difficult. To apply for a residency (the equivalent of Specialist training, but which is done striaght after med school), I need to take two exams, one of which has to be taken in Canada. I'd also need to get permanent residence in Quebec (but why would they offer me residence without a job?). And only then could I even apply.

It's a hell of a lot of paperwork, but I could do it if I really wanted to (this elective required a lot of paperwork, and I managed that). But it also costs £500 to enter the exam. So I'd have to be certain about it. That'd take two years, and who's to say I wouldn't have a partner by then, a house, commitments, etc? It'd be 4 years here, by which time I'd be a Canadian specialist so couldn't go back to the UK without reconverting back etc. So I'd kind of be signing up to emigrate.

But I know people at med school who are already taking USMLE (the American equivalent). What future does the NHS hold? Maybe there won't be enough training posts anyway for my year group in 2 years (scary thought that I'll be applying for ST in two years...) so it'd be worth having a back up.

I'd love to do it. I just don't know if I can. Everything is set up for me in the UK- I'm on the conveyer belt and will be packaged off into the plastic bag of one speciality or another. But to move- that'd be jumping off my conveyer belt, filling in a zillion forms and trying to hitchhike to a supermarket in a different town (imagine I'm a carton of milk) just to get on a different supermarket's conveyer belt.

Oh but I love this country. I want so much to come back, but why do they have to make it so damn hard?!

Maybe I should just marry a Canadian...

This post could seriously damage your health....

I went to see a French film today. Despite being in a French-speaking city, I have done very little of it- my collegues are Anglophone, so are my friends, so are half of the patients. So I thought I should give French a chance.

The film was a documentary called Quebec sur Ordonnance (Quebec on Prescription). I'd heard people talking about it, and thought it sounded interesting, so off I went, to try and get through a foreign film without subtitles (The woman at the box office looked utterly perplexed when I asked if it had subtitles “Non….It’s in French. Why would it have subtitles?”)

The basic premise of the film was this: Drugs are baaaaaaaaaaaad (but the pharmaceutical industry is badder).

The themes of the film: Children on (prescription) drugs- bad, Old people on drugs-bad. Drug companies give doctors freebies- bad. Anyone can get antidepressants if they tell the GP they’re depressed (I hate these ‘set-ups’ using actors, it always seems a bit unfair).

A doctor made a mistake with a drug dose and my baby nearly died. A nurse made a mistake with a bag of fluid and my father did die. Prescription drugs bought on the street or the internet are very dodgy and may contain arsenic (this I agree is a Bad Thing). Psychiatric drugs-especially bad (Cue patient saying they take such-and-such for their ‘anxiety’- screen then shows it’s a big bad nasty antipsychotic and lists about 25 side effects).

All drugs are placebo effect anyway (Shopping centre experiment where people are given a placebo pill ‘to make them feel good’ and after 10 minutes they all agree they were sceptical, but it really did work) .

And finally , as the pharmaceutical industry only creates 4-5 new drugs a year, to make a profit they have to find new markets and so creates new diseases where there was none before, purely for their own financial gain (Which isn’t entirely untrue but their use of high cholesterol as an example was a bit odd).

The only point at which they came out in favour of medication was with a man, let’s call him Michel. Michel was chopping vegetables fifteen years ago when he heard a voice telling him to kill his father, which he then did (cue scary silhouette in background of man being stabbed), and has been in a secure unit ever since. Michel then showed us the two pills he took, one for his ‘anxiety’, the other for his sleep.

“And what would happen if you stopped taking them?” said the commentator ominously.

“Oh, the doctors tell me I’d hear the same voices again,” Said Michel cheerfully.

The moral of this story: Most people don’t need to take psychiatric medication, except when it’s stopping them from killing people.


And people wonder why mental health has so much stigma surrounding it……

* * *

In lighter news, my new favourite food is this:

What it lacks in nutritional value, it makes up in ridicoulosly artificial colouring.

I wonder which big pharma will soon be coming up with a pill to stop me getting hooked on it….

Delusions of Grandeur

It's funny what happens to me inside a hospital.

I'll be walking along the street, earphones in ears, beanie on head, scruffy coat with a few buttons missing on, typical student, engrossed in my own thoughts and my own music. I could be any other student, on their way to lectures or (more likely) on their way to get a coffee, to see them through a boring day.

I walk into the hospital, down the corridor, and still I could be anyone, a patient, a family member, or a member of staff. I'm completely anonymous.


Then I step into the doctors office, take off my coat, take off my earphones and enter the real world, feeling completely different. Feeling like I have a job to do, like I know where I'm going with my life, and like I can do it.


Do you remember Stars in Their Eyes? You'd get some 40-something housewife, telling you she enjoyed walking her dogs and doing watercolours in her spare time, then: "Tonight, Matthew, I'm going to be Madonna," and she'd step into the smoke, and when she stepped out, all peroxide wig and plastic crucifixes and fingerless gloves, for a second, just a second, she really was.


That's how I feel.


I go in feeling like this :

And I come out feeling like this: (who one of the patients said I sounded like!)

And tonight, Matthew, I'm going to feel good about it :-)

Stuff I'm learning...

Hello everyone. Apologies for absence, and possibly some in the next few weeks as now I'm starting to worry slightly about the MTAS form which will have an impact on the next two years of my life.....

If I spend too much time on here, I may end up in Hull....*

Anyway I thought I should share some stuff about Psychiatry I have learnt since being here (God, this sounds like an MTAS question already...but anyway).

1. Personality disorders are much more subtle in real-life. They're not 'larger-than-life' like in the textbooks. Also: don't get misled by one trait. Not every self-harmer has Borderline Personality Dorder. Not everyone who believes their horoscope is Schizotypal.

2. Similarly, don't over-estimate psychopathology when it's not there. A 17 year who has 'alternaive theories about religion' is probably not in a prodrome for Schizophrenia. (As was pointed out to me, most 17 year olds have alternative theories about religion....)

3. The exception to 1&2: all medics have traits of Obsessive-Compulsive personality disorder.

4. Anything that's not quite depression, but has traits of it can be classified as 'Adjustment disorder'.

5. ER is chaotic, but also quite exciting.

6. All drugs are called by trade names here. It's quite acceptable to ask what the generic name is.

7. If you still don't recognise the generic name, you can say "We don't use that in Britain". (Sometimes true. Sometimes not. But a friend on elective in America told me she also does the same!)


I'm actually loving what I'm doing at the moment. Wish I could stay longer, but the NHS needs me (!)




*In all fairness, I've never been to Hull. It may be lovely, but there's got to be a reason that it's the least popular place in the country...

Sometimes you have to wonder who the psychiatrists are....

Another on-call, another free meal ticket.

As I queued up to 'pay' with my 'on call meal ticket', the guy at the till smiled at me and said "Have a good on-call tonight".

I thanked him.

As I picked up my tray, he said "Psych, right?"

I have never met this guy before. I was not wearing my "You don't have to mad to work here but it helps" badge. I did not have a top pocket filled with sedating anti-psychotics. I do not have a beard.

Google images reckons 'psychiatrist' looks like this:



Or alternatively this:

(I'd rather look like her, although she looks as though she's thinking "Oh my God what should I do with this small child? Well, the drugs company of the website I'm modelling for make Haldol...now there's a thought...")

I look like neither of these. You couldn't even say I had 'acquired' a look of the psychiatrists here, as I've been here 3 weeks (and done about 7 weeks of psychiatry prior to that). There's nothing on my badge to say psychiatry, I wasn't carrying a psychiatry textbook on me, nor was I with any other member of the Psych team.

So I asked him how he knew.

He replied, with a grin "It takes a special kind of person to do psychiatry."

I can't work out if this was a compliment or not.

Medical Student Syndrome

The path to doctordom is littered with the murky pits of self-diagnosis.

During the course of medical school, I have wondered whether I have had, at some point or another: diabetes (type 1 or 2), migraine, angina, gallstones, a pituitary adenoma, pneumonia, stomach ulcers, inflammatory bowel disease, renal stones, motor neurone disease, glandular fever, and some other more embarrassing things I’d rather not mention.

(In a few cases (not listed above) I have been right-however the majority of the time I have been, fortunately, wrong.)

Since becoming acquainted with psychiatry I have ‘diagnosed’ myself with: virtually every kind of mood disorder, a few of the anxiety disorders, a couple from child, and a couple from old age (yes, really!) psychiatry, and about 6 kinds of personality disorder.

(And before you shout ‘hypochondriac!’, most medical students I know are exactly the same. It’s an occupational hazard. In fact I just googled it and it even has a wikipedia entry http://en.wikipedia.org/wiki/First_clinical_syndrome)

What doesn't help is being around a bunch of people who have made it their career to worry about other people's mental health. The other day, I was having lunch with a group of people, talking about our ‘idiosyncracies’. I happened to mention, entirely light-heatedly, that I don’t like listening to albums out of sequence. (You wouldn’t read book chapters out of order, nor listen to a piece of classical music with the movements shuffled, so why do it with pop music, when the artist has chosen to put the songs in a particular order?)

The young resident on the table looked at me, put down his fork and said “Ah….so you’re an obsessive. What would happen if you did hear the songs out of order?”

I don’t know….I’d explode? No, nothing. It wouldn’t upset the rest of my day. I wouldn’t worry bad things would happen. It would just be mildly annoying.

This is a quirk. Everyone has them. Some people, dare I say it, might even find it endearing. One quirk does not a psychiatric diagnosis make.



On the road I live on, there are two lovely horse chestnut trees. On the ground there are scattered some lovely ripe conkers. Being from Britain, my natural instinct on seeing a conker, expecially a good one with nice sharp edges, and a flat top, is to pick it up (despite the fact it must be 15 years since I last played conkers). So I had a few in my pocket, reminding me of home, and generally not doing any harm.

I went to a seminar and slung my coat over the chairs. At the end of the seminar, the other students and I started to leave, when the guy doing the session noticed something on the polished wooden floor.

“What’s this?” He asked, examining it closely between forefinger and thumb.

“Oh,” I said, embarrassed “That’s mine. It’s a conker. It must have slipped from my pocket. I picked up a few on the way”

He looked at me directly, raised one eyebrow, and, with an amused smile on his lips, he said “So….you like to collect things?”

Off The Radar

I love this city. Everywhere I go, I meet people equally passionate about it as I am. They come from Toronto, Vancouver, New York, London, Norwich (!), France and from Montreal itself. They all say things like "Well, you can't put your finger on what it is..." "It's got a kind of atmosphere" "It's so relaxed", and it's always followed by "And it's so off the radar."

Which is all true. Montreal doesn't have many 'sights' as such. There's no big tower, like Toronto, no museums like London, no goverment buildings or palaces like Berlin. People never put it on their lists of 'five places in the world I really want to go to.'

And yet, it is truly amazing.

Take this weekend- I saw a gig in a tiny venue, then went dancing in a club where the seats were like the backseat of a 50s car in red leather, complete with metal footplates. We wandered out at 2 in the morning and the streets were bustling with people, eating 99 cent pizza slices. On Saturday we walked around St Denis (trendy shopping street) in the pouring rain, while I continued my mission to find cheap cufflinks (shirt needs them, I forgot them) in antique shops, and hippy markets. We drank beautiful hot chocolate in a place done like a French bistro from the 40s, then later ate noodles in a place where you chose your own combination of stir fry. In the evening, we went to a club that was basically like a house party if you had a friend who lived in a stately home, and danced til our feet ached. And everywhere we went, people talked to us, and shared their enthusiasm overwhelmingly with us.

The thing is, most people equate 'hip' with pretentious, but here it really isn't. There's no attitude at all. Everyone enjoys the variety and celebrates it. You don't need to see the 'landmarks' to have been here, you need to drink a coffee in a cafe overlooking the street and watch the world go by, you need to rummage in the 'fripperies' (antique/vintage cloth shops) and you need to stand on top of Mont Royal and gaze at the Manhatten-esque skyline surrounded by the changing colours of autumn. It's beautiful.

Had Thanksgiving yesterday at a British student's place that I randomly met a club. As someone who knows nothing about Thanksgiving, it was nice to learn it's mainly just about eating turkey, and stuffing, and creamed potatos and apple pie. I could get used to this! (I have another Thanksgiving tonight!). I love Canada.

And this is my collegue, Dr Sham....

I love on-calls. I really do. I love it when the hospital goes quiet and the minorly-ill and injured go home, leaving only the sick and the dying. Not to mention the patients :-p

Seriously, I do though. I like the sense of camaradie that develops between staff members, I like the dimly lit corridors, and I like the buzz you get half-way through the night. (Which is why I loved O&G, although that had the added bonus of a baby at the end).

What's really great here are the on-call meal tickets. Those who say there's no such thing as a free lunch should come to Canada. Far from the stale, unidentifiable meat sandwiches of a Grand Round back home, here you get a ticket purely for monetary value in the canteen. Given the currency conversion, and the fact everything here is so much cheaper, I'd say it's probably worth around £6. You can take anything you want from the canteen up to that value (and if you don't use enough, the canteen staff encourage you to take more food up to that value.) It's all very exciting.

(Listen to me: the perennial student...I worry one day I'll be a consultant still getting excited over free food while my students giggle at me, and call me Dr Cheapskate behind my back)

Something I'm having problems with: talking to psychotic patients. In French. In perculiar French. But at least now I can say in another language "Sometimes, when people feel a bit low, they hear voices when there's no-one in the room. Has this ever happened to you...?"

Something else I've noticed is that I get introduced by other doctors to patients as "Dr [surname-let me call myself Dr Anonymous for now]". At first I thought it was because they assumed I had qualified, but it turns out all medical students here are Dr ..., followed by 'my student' or something like that. I'm in two minds about this. I'm quite used to being called "[first name], one of our student doctors". I'm also used to having "Doctor!" shouted at me by old ladies who need their catheters changing (or more likely, being female: "Nurse!") But Dr Anonymous ? On the one hand, I feel completely unqualified, as if it's a fraudulent title and all the patient hears is the word 'doctor' and assumes I am one. Having never heard myself called Dr Anonymous before, it also sounds very strange to my ears, as though, after five and a half years of this, I think of myself as a permanent medical student, but never a doctor.

On the other hand, I quite like it :-)

* * *

It seems the last post gave the impression that psychiatry was a bit 'hocus-pocus' and not really very scientific. That wasn't really what I meant at all. What I meant was this: Just as it takes a certain kind of doctor to tell people day after day after day they've got cancer (and you can know all you want in the world about gene mutations and abnormal mitoses, but it doesn't help when they look you in the eye and say "Well? What did the test results show?"), it takes a certain type of doctor to ask someone why they wanted to end their life, and for the patient to trust them enough to tell them. And the people I work with do it so well, I'm completely inspired.


That's enough for tonight. Dr Anonymous is going to sit around practicing being a doctor, not thinking about free lunch.

The Kleenex Reflex

One of the things I've noticed about the way psychiatry is practised here is what I like to call the Kllenex Reflex. A box of tissues sits on every table in every consultation. What's incredible however, is how skilled everyone is at using it. Before the first tear has even slipped from an eye, before a voice even chokes, the psychiatrist has offered the box of tissues, and so smoothly that it doesn't look awkward, or affected, but just right for that moment. It says "I know you're about to cry and I'm responding to that." (Edit: I just re-read that and it sounds like psychobabble, but it's how it was described to me.) And having been on the receiving end of it, it really works.

In all seriousness though, I'm really enjoying watching good psychiatry here. There's a general misconception in medicine that psychiatry is 'easy', that it's just a matter of asking a few questions and prescribing a few drugs.

But it's a bit like one of those Magic Tricks Revealed shows. You can learn how the trick is done, and you can repeat it in front of your friends, but it really isn't just about knowing the moves. You need to have just the right slight of hand, the perfect timing, and the ability to engage your audience. It's the same in psychiatry, in order for the patient to respond to you and engage with you. Done well, it's an art form. It's almost sexy. It's certainly inspiring.

When it comes to my turn, I think I know what I'm doing, but my questions, in comparison, seem clumsy and awkward, to the point of being painful. But then, suddenly, out of the blue, you get a 'click' like the one described by Samuel Shem in Mount Misery, and voila, (rabbit from hat) you feel, at last, that you might just be getting there :-)