Panacea Volume 53 Issue 1: "Finding Failure"

VOLUME 53 | ISSUE 1

panacea THE OFFICIAL AUSTRALIAN MEDICAL STUDENTS’ ASSOCIATION MAGAZINE

“FINDING FAILURE”

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TABLE OF CONTENTS EDITOR’S FOREWORD 5 Linna Huang AMSA’S ADDRESS TO THE AMA Jessica Yang

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FAILURE TO HEAL 10 Michele Fu and Wai Chung Tse GREYHOUND 12 Thaddeus McFarlane THOUGHTS ON FAILURE 14 Tilly Robertson CROSS-STITCHING ORGANS 15 Marianna Boscariol I BROKE UP WITH A BOY USING SPIKES Janis Fernandes

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RICHEST MAN IN THE CEMETERY Kira Muller

19

THERE WAS AN ATTEMPT Brooke Carmody

20

ON FINDING FAILURE 22 Merryl Rodrigues ON ONE OF MY DOWN DAYS, I SEEK HELP Anonymous Submission

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CATEGORY IS... GROWTH 26 Conor Cusack NLDS REPORT 30 Matthew Kim VAMPIRE CUP REPORT 31 Corinne Antonoff

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Editor’s foreword Linna Huang AMSA National Publications and Design Officer University of New England/Newcastle Year IV Thanks for picking up this issue of AMSA Panacea - AMSA’s biannual magazine. This issue’s theme was “Finding Failure”. Here, you’ll read about issues and concepts that are important to medical students regarding their own interpretation of finding failure.

Thank you to everyone who submitted articles for this issue of Panacea. This edition, all submissions were put into the draw to win a copy of the incredible autobiography “When Breath Becomes Air” by Paul Kalanithi. Congratulations to Brooke Carmody on winning this prize in this submission round! Keep an eye out on the AMSA Facebook page for future Panacea submissions.

A massive shout out to my Publications Team for their hard work in helping me source articles, write them and put it all together.

If you have any questions about this issue, or about any of our AMSA Publications, please feel free to email the publications team at pdo@amsa.org.au

Acknowledgements EDITOR-IN-CHIEF Linna Huang (UNE) PUBLICATIONS TEAM Sarah Broome, Editor (Monash) Hayley Fancourt, Editor (ANU) Wai Chung Tse, Writer (Monash) Michele Fu, Writer (UNSW) Neha Vetnani, Digital Artist (Griffith) FRONT COVER Neha Vetnani (Griffith) ADDITIONAL ACCOMPANYING IMAGES Michele Fu, p3, 14 (UNSW) Daniel Zou, p18, 24-5 (UMelb) Wai Chung Tse, p19, 22-3 (Monash) freepik, p8

SPONSORSHIP OFFICERS Cai Fong (UQ) John Shenoda (Bond) WITH SUPPORT FROM

On May 26th 2019, I had the privilege to address doctors at the Australian Medical Association National Conference in Brisbane about issues that medical students are facing. Most important was the call for leaders in the medical profession to use their visibility to lift others up and to take care of each other. This is a transcript of the speech – you can find a recording of it on the AMSA website.

Aussies can relate to, and are proud of. Maybe not the helicopter part. But the bridge between my ethnicity and my nationality was one that I struggled with. When seeking support for my Presidential bid, I had specifically been told that my age, gender and most pertinently, my race, would make me an unattractive candidate. “You don’t sound Asian,” a stakeholder told me, “so you’ve got that going for you.”

I am thankful for the privilege to study medicine and to be representing 17 000 of Australia’s future doctors. My name is Jessica and I am studying at the Western Sydney University School of Medicine.

When I was elected at AMSA’s Second Council last year, I was informed that I was the first nonwhite AMSA President.

I am thankful for my identity and my upbringing. I come from a diverse background; I was born in a helicopter flying from a rural island off the coast of Hong Kong, so my parents insist I was born to soar to great heights. My parents are from China but they grew up in Japan. When I was 10 months old, my family moved back to Australia where I now live in Western Sydney.

Mine is a dynamic, cultural experience that many

My first reaction was one of disbelief. I am surrounded every day by my colleagues from all backgrounds; when you consider the diverse makeup of the medical workforce, whom society looks to as leaders, how can our leadership not reflect this?

A friend of mine who is of Indian background, told me, “You should be proud. Because of your visibility, more people who may not fit the mould of a conventional leader will be encouraged to put their hat in the ring.”

I responded to this with indignation and fear. Why was it now up to me to lead a crusade of diversity within medical student leadership?

As you’ve probably gathered, these two reactions were incongruent: I was simultaneously complaining about the current state of representation but was wary to take ownership of the opportunity to make change.

I thought back to an interaction in 2016 I had with the now AMA(NSW) President, Dr Kean-Seng Lim. He told me “There needs to be more people like you at the table. Make sure you stick around.”

for what my future holds.

I went to the only local GP available after-hours.

I was convinced I had developed narcolepsy as I frequently found myself on the verge of falling asleep throughout the day, most worryingly, behind the wheel. Perhaps I did have a temporary bout of stress-induced narcolepsy. Or, perhaps I didn’t want to admit I was burning out.

If this is the environment in which we start our journey and form our habits in medicine, what happens when we have the responsibility of patient safety on our shoulders? We work harder, and longer and become more tired. We make mistakes.

Remembering this, I realised: it’s not about me. It is about my 17 000 peers who have given me the privilege to speak on their behalf.

Many people in this room have “If this is the environment the same privilege to represent in which we start our their peers and I implore you to journey and form our use this opportunity.

Use this experience to look out for those who do not have the same opportunities to speak up or create change. Use your seat at the table, use your visibility to lift others up, so they can be visible too.

habits in medicine, what happens when we have the responsibility of patient safety on our shoulders?

We work harder, and longer, and become more tired. We make mistakes.”

It would be remiss of me not to mention Dr Yumiko Kadota when discussing non-conventional medical leadership. She published her personal story on her blog “The ugly side of becoming a surgeon” where her experiences as an unaccredited registrar working 180 hours on call shocked the general public.

Unfortunately, for many of you in this room, and for those around me at medical school, this story of burnout and a lack of systemic support is not one that shocks us, it is all too familiar.

I recall my own experience as a student last year, which required a reasonable 35 hours per week of clinical contact. Then add 20 hours of recommended study, 20 hours of part-time weekend work to pay my rent, plus a 2-hour daily commute; any remaining time was spent simply surviving. This does not hold a candle to Dr Kadota’s experience, but it does makes me worry

Considering these experiences makes me think more broadly of the current state of medical education and training. HDs in exams, getting multiple degrees, “CV buffing” - these things certainly require talent, and look good on paper, but are we becoming better doctors in the process? Nobel Prize-Winning economist, Michael Spence, observed the phenomenon where people pursued achievements to “signal” their worth, rather than to improve their skills.

Medical students are watching, and we’re worried. We see our mentors, who are vastly more qualified than us, fighting unprecedented competition for specialty training. We watch our recently-graduated colleagues, who are pursuing a PhD for no other reason than to improve their chances of getting into training.

We hear stories of extracurricular courses and pre-training exams which contribute to a very expensive curriculum vitae, just to keep up with shifting college goalposts. We think to ourselves “how am I ever going to get there?” Know that we are watching and listening to you, and we see that you are under pressure.

This pressure is filtering down into medical school. I was recently at an orientation week and a group of half a dozen first years approached

I was humiliated. I felt belittled in my capacity as a leader and belittled because of my gender.

This is the type of insidious behaviour that is perpetuating a toxic undercurrent of medicine.

Many of us shrug it off, but I am asking you to call it out as my peers did for me at the time.

While I am uncomfortable recounting this, as someone in a position of power I have a duty to do so, and so do you. We should empower those who are belittled and disregarded as unimportant because that is how we will create change.

When we express dissatisfaction with the status quo, medical students are told “it is your generation that will lead the change. Just hang on until the old ones leave”. Please, stop telling us this - this idea of generational change only serves to isolate you from us. And we should be working together, now more than ever. the AMSA stall. They were asking about how to get involved. Great! I thought. I asked them why they were interested in joining AMSA. “Honestly Jess, because extracurriculars look good on a CV”. This was their third day being a medical student; for some of them, it may have been their third day of university. These students have not stepped foot in a hospital and are already thinking about how to outdo their peers in 10-years’ time.

At last year’s AMA National Conference, a motion was passed to credit postgraduate clinical experience more heavily in specialty college applications, rather than the current focus on academia. I applaud this preventative step in addressing an increasingly competitive climate.

It reinforces the idea that we should be working with each other for our patients and their safety, instead of adding lines to our CV, which do not drive our passions or improve our clinical ability.

Recently, I spoke at an event before a plenary by an incredibly impressive and well-regarded doctor. As happens with many conferences, my talk was pushed back and subsequently so was his. He expressed his annoyance by telling the audience that I “should not have spoken before him” and then telling the event staff that I was a “naughty girl” and what I had to say was “irrelevant”.

We cannot wait for change that may never come.

We ourselves cannot change if we continue to advance into a system that disengages us and makes us cynical.

This conversation is not new to anyone in the room - we have heard these calls to action over the weekend, and even over the years from my predecessors. I would urge you to reflect on your time in medicine: what made your life better and what challenged you? What was the worst thing that happened to you as a student or junior doctor, and how can you stop it from happening to someone else?

“The medical profession can do amazing things when they stand together for a common cause.”

The medical profession can do amazing things when they stand together for a common cause. Last month, AMSA was accepted as a stakeholder at the United Nations High-Level Meeting on Universal Healthcare. This incredible opportunity for international advocacy was only made possible; by the tireless work done by hundreds of medical students who volunteer their time for AMSA and for our community as a whole. They juggle medical school and these demanding roles to improve the system for those who come after us.

The video played at the start of my address showcased the ability of passionate medical students to make change. In January, AMSA publicly supported pill testing trials and improvements to harm minimisation initiatives.

In February, AMSA implored parliamentary support for the Medevac bill. In March, AMSA rallied to demand action on climate change and its effects on health. On each of these issues, we stood beside the AMA and together, our voices were collectively amplified.

These are the issues that your future members want to see you fighting for and need your support on. I am thankful for Dr Tony Bartone for being so supportive of our advocacy efforts and for actively welcoming me to the leadership table.

I have touched on a lot of different issues today which all come back to a fundamental need to change the status quo. These issues may seem insurmountable when heard back-to-back in fifteen minutes but I ask you to consider the old adage: how do you eat an elephant?

One bite at a time. It takes hard work to lift up your juniors, your medical students, and those without a voice, and to take them along with you on the ride. But it only starts with small acts of kindness: tell people to stick around, call out offensive behaviour and take care of each other.

Thank you.

Jessica Yang is the President of the Australian Medical Students’ Association, the peak representative body for Australia’s 17 000 medical students. She is a medical student at Western Sydney University. She can be found on Twitter at @YourAMSA and @JessHYang.

Failure to heal

by Michele Fu and Wai Chung Tse UNSW, Year III; Monash University, Year I My curiosity towards palliative care began with an idea – a notion that perhaps we are not as important as we think.

In my first year at university, I experienced a lingering sense of hopelessness and doubt. For what are we working towards each day if we, our friends, family, peers and patients will eventually pass on and be forgotten? I came to realise that it is the limited time we possess that should motivate us to make the most of what we have. I am sure many medical students find purpose in the hope that, as future physicians, we will be capable of healing others and aiding a patient’s journey to recovery.

To many, a doctor’s role is simply to cure. As physicians in training, our education revolves around learning about the illnesses we can diagnose and treat. Armed with these tools known as “medicine”, we commit our lives to the service of others, often sacrificing all too much in the process of fulfilling this ideal.

However, we are never prepared for the failure of our “medicine”. What would the doctor’s role become if the patient was incurable?

Palliative care aims to improve the quality of life of patients with chronic conditions or terminal illness through symptomatic relief. In Australia, there are only 190 palliative medicine specialists, or one for every 828 deaths (Palliative Care Australia, 2019). On entering medical school, palliative care was a specialty I understood little about, and consequently had little appreciation for.

As I entered the hospital, it became clear that I was not the only one who struggled to embrace palliative care as a treatment option. In ICU, I found myself in the midst of newly graduated medical students. We were briefed on a patient who faced a terminal illness. During pre-rounds, we discussed the treatment plan for the patient, considering algorithms and journal articles to develop a plan.

When the attending arrived to discuss our patient, I noticed the residents’ aversion to confessing that treatment would be of little help, each attempting to escalate care as if the consideration of death was a taboo. It wasn’t until the attending brought up the idea of palliative care that the residents reluctantly nodded in agreement.

This reminder of the presence of palliative care as a management option was something I swore to hold close to my heart as I progressed through my medical career. Alas, destiny saw that I would make the same mistakes.

When confronted with the challenge of explaining a terminal cancer diagnosis to a simulated patient, I found myself mirroring what had occurred in the past. During the explanation, I struggled to introduce the subject of forgoing treatment if the cancer progressed. It felt as though I would have failed him if he exited the consultation without an offer of treatment.

A group project in second year gave me the privilege of interviewing a palliative care patient with motor neurone disease. Even though I had researched the condition prior to the interview, no amount of theory could prepare me for the moment I drew the curtain and met her eyes. I was shocked by

For me, a young student who held and still holds an insurmountable admiration for modern day medicine and its ‘miracles’, the word ‘terminal’ was in itself confronting.

her physical appearance as she spoke, gesturing with hands so fragile I feared they would snap. Her legs were thinner than my wrist. Yet, when queried about her healthcare team, she smiled. For me, a young student who held and still holds an insurmountable admiration for modern day medicine and its ‘miracles’, the word ‘terminal’ was in itself confronting. However, from that point on, I understood that the role of a medical practitioner extends far beyond curing their patients.

In today’s medical world, it seems as though we have become increasingly focused on offering solutions to our patients. In part, this is perhaps motivated by the process of quenching our desire to help, whilst losing touch of our patient’s greatest concerns - that they seek not just treatment, but consolation.

When doctors bring humanity to the service of others, we bring our passions, fettered by our sufferings and our hopeless desires to change the world with us. Yet, it is this human condition that urges us to cure every patient that seeks our help. Recognising this will allow us to accept the deep-seated desires of our patients - that healing is not about offering solutions, but about standing with the patient till the very end.

And in the very end, in the midst of the beeping monitors, there was a stillness that came over the ICU as I watched the patient we were initially consulted on. Although we were late in realising the failure of our “medicine”, we were eventually able to acknowledge the true desire of our patient. In that ward filled with freshly minted doctors, the patient passed away peacefully in the presence of her family, finding solace in the midst of her suffering.

Perhaps one day, we will accept our inability to treat each and every patient we meet, and instead realise that as physicians, “we will cure sometimes, treat often, and comfort always” (Hippocrates).

And through this, we will understand that failure does not lie in the inability to heal, but the inability to find the courage to accept our flaws.

GREYHOUND

By Thaddeus McFarlane Griffith University, Year III I heard an interesting analogy the other day.

It started with a retired greyhound who’d spent it’s life running in circles with one goal; to catch a bit of felt that looked like a rabbit. One day this dog was at the park and slipped off it’s leash. It spotted a cat - one that must have looked like that piece of felt. He ran and ran. Chasing the cat, his life dream. He caught it, killed it and then he just sat there confused. It had spent its whole life trying to catch the thing it had just caught and now, it had no idea what to do.

This really resonated with me. It reminded me of my life and my pursuit of my dream to be a doctor.

Am I this greyhound? Will I get to graduation, my greatest goal in life so far, and not know what to do?

There is a good chance I will get there and be lost, but is there anything wrong with feeling like that? Like we are always told, uncertainty is the only certainty in medicine and I plan to embrace that.

I have spoken to many medical students who are ‘so looking forward’ to being a doctor and can’t wait. When I ask, “what about being a medical student? Why can’t you enjoy being one now?”

They usually reply “Medical school sucks!” This frustrates me but is understandable as when we are kids, no one ever says “I want to be a medical student!” We are always chasing the best or we want what’s bigger and better. Why would you want to be a medical student when you will eventually be a doctor anyway? I will give you a few reasons why.

1. Don’t want to be the greyhound The greyhound only had one thing on its mind; catching that felt rabbit. But when it did catch it, all wasn’t as it seemed. Medicine can be like that. Most of us spend our whole life dreaming of getting there and when we do, it’s usually not what it seems. Don’t fall into the trap of not knowing; do your research as to what junior doctor years are like so you don’t become the greyhound and live with unrealistic expectations.

2. Lots of space in that basket for more eggs More eggs are better than one and more yummy, especially with some pepper and toast. Hobbies are great, and a lot of doctors will ask you what your hobbies are outside of medicine because it’s crucial to health and wellbeing. Having other things in your life like exercise, reading, friends or jobs are all good ideas to get away from medicine but also add to the dish of life. Similar to how having more eggs in your breakfast makes it more yummy and fulfilling.

3. More to life than medicine Medicine can be all consuming if you let it, however, I’ve found the most enjoyment comes from when you enjoy things outside of the hospital. In the end, we are all human beings and medicine is just a job. What can you do to help others in your time off? Can you learn a new skill? Hang out with friends or family? Exercise?

Read a book? Medicine will always be there, but your life outside will disintegrate if the effort isn’t maintained. Remember, there is more to life than medicine!

4. Plant those seeds so you can smell the flowers when they grow Getting in good habits now with regards to making time for yourself will come in handy and set you in good stead for the future. We all know it’s going to be harder to find time when you become busier as a junior doctor with responsibilities. If we compare it to a garden, planting the seeds in med school now will give the flowers (your self care skills) time to grow and mature by the time you are a junior doctor. Fully grown flowers only require water and the occasional fertiliser top up, obviously this takes less time and less effort than planting new seeds all the time.

5. The ‘P’ word Perspective. It is my favourite word. It can change, grow, broaden, and solidify just to name a few of its many talents. It is an extraordinary word that can change your life for the better if you open up and challenge yourself. Changing your view can be hard but is often worth it, even if just for a moment.

I hope these resonate with you if you are reading this and you are able to help yourself to become the best medical student and best young doctor you can be in the future. If you are interested in talking to me more about this topic, or just want to chat in general, send me a Facebook message or email me at Thaddeus.mcfarlane@griffithuni. edu.au “The world is what you make it, and you see it how you want to see it.”

Love, Thaddeus McFarlane

Thoughts on Failure

by Matilda Robertson Bond University, Year III Thoughts run around in my head I toss and turn The thoughts can’t be shared.

No, no one will understand It’s complicated.

I feel safer in my bed Tomorrow is a new day It will be better The thoughts will disappear then.

Summer sun shines through I groan.

Another day to face I drag my feet to my destination Exhausting.

Just arrived, ready to leave Someone asks me a question So little to say, But so much to think Should I share my thoughts?

No. They won’t understand Surely no one wants to listen Deafening silence.

The thoughts grow bigger In that conversation I don’t have Here, I find failure.

(I would’ve never guessed: They were willing to listen)

Crossstitching organs

by Marianna Boscariol University of Queensland, Year IV I cross stitch since it is how I meditate and practice mindfulness. I’m able to clear my mind and focus on the repetitive motion of pulling the needle and thread through the holes and counting squares to complete a pattern. I like to design unconventional and quirky cross stitch patterns, especially involving medical subjects.

I BROKE UP WITH A BOY USING SPIKES …and it was the best break up I’ve ever had.

by Janis Fernando Griffith University, Year II I’ve grown up on a steady entertainment diet of Taylor Swift, teen rom-coms and Disney. Dramatic confessions of love are all I’ve ever known. My relationships have always been filled with soaring heights or the deepest of lows. From mountain sunrises to crying in car parks, I am a living, breathing tumblr quote. However, to clarify, I am not an emotionally unstable person. I just go big or go home. Mostly, I go big. If you filmed my love-life, it would be a be up there with La La Land or The Fault in Our Stars. Okay, maybe not quite, but in the interest of drama...

genuinely empathetic and more self-aware.

I was handed the opportunity to really put my communication skills to the test when I had been seeing a boy for a few months and realised that I didn’t see it working. I liked him, I didn’t want to hurt him or ‘ghost’ him and leave him confused. This is a terrible position to be in - knowing that your actions, your words, are going to hurt someone but having to tell them anyway. It’s a hard conversation to have and, arguably, there is no right way to have it. I’d been processing for days, trying to think of the right words to say to make a hard blow hit softer.

I’d had enough drama in my life, I wasn’t looking to I suppose my attraction toward melodramatic create more. relationships is, or was, really just a manifestation of immaturity. As I’ve aged, I have realised that Unfortunately, we had certainly never had a rollercoasters are best left to theme parks instead communication skills session about how to of emotions. Although thrilling, they bring more break up with boys. pain than fulfillment. The crashing, burning, SPIKES was the closest thing I had. breakup that is followed by shredding his letters and ringing at 4am a month later is, to put it mildly, unhealthy.

Unfortunately, we had certainly never had a communication skills session about how to If my medical degree so far has taught me anything, break up with boys. SPIKES was the closest thing it is that emotional regulation is imperative. Keeping I had. From my adventures in communication emotions in check allows better clinical reasoning, I’ve learnt that every conversation goes beyond greater focus and more effective communication. just words. It requires responding to emotions, It allows me to interact with people in a way that validating ideas and creating clarity. I don’t mean maximises the productivity of an encounter to reduce a relationship to a clinical encounter, but and minimises the messiness. It maximises the the similarities are irrefutable. Both are complex responding part of communication and minimises interactions where improperly executed empathy the reacting part. In the last few years, these can create miscommunication or unrealistic communication skills have permeated my daily expectations. The fear of distressing someone life. They have definitely saved me in painfully slow leads to avoiding the conversation altogether and conversations with people I went to high school creates its own complicated tangle of issues. Poor with and run into at a party, but they have also communication makes messy things messier. I made me more attentive in conversation, more didn’t need more mess.

S is for set up, I thought. This was a quiet room, face-to-face, no distraction conversation. This was not an improv, “see what comes out of my mouth in the moment” conversation. This was a think and feel and know what I want before I enter the room conversation. But regardless of how sure you are, entering that room, knowing the damage you might do, is nerve-wracking.

A sigh, a hug, a squeeze of the hand.

“Goodbye”.

“Bye”.

There was no, “I’ll always love you”. No last-minute doubting that leaves you feeling confused next week. There was no shredding of letters or poorly constructed, blubbering, voicemail. There was only one watch of 50 First Dates in bed with too P is for Perception and I needed to understand his. much ice-cream and there were absolutely no hard “Before I tell you what I’ve been thinking, tell me feelings. where you’re at with us,” I said.

Talley and O’Connor would be proud. But then came As far as break-ups go, this one was peaceful. I the hard part, now I had to tell him I was done. No didn’t have to tactfully avoid him at the supermarket matter how sure you are about what you want, it’s or scroll through his Instagram on a weekly basis in not easy to let go of someone nor is it easy to see the months that followed. I wasn’t tormented by the the consequence of your words manifest as they thought that I had made a terrible mistake. SPIKES were about to. Warning shot loaded, I collected helped me to replace confusion with clarity and myself. Honestly, simply and without excessive communicate bad news in a way that left neither bluntness is how I’d been taught to break bad news party bearing a responsibility that was not theirs to so that’s what I did. bear. Often, when we are the bearers or recipients of bad news, we feel personally responsible for it.

I was met with tears and confusion. The words This guilt attaches itself like an anchor, regardless “I don’t understand” came over and over. Sitting in of the fact that it’s not your fault if you don’t want tears yourself, it’s hard to do the E part of SPIKES, a relationship with someone. SPIKES facilitates but I tried my hardest. I verbalised the confusion, understanding, empathy and factually correct addressing the shock-factor of a breakup, allowing information delivery that minimises guilt and room for the feelings to be extrapolated. Confusion allows closure. breeds anger and anger breeds resentment so we worked through the confusion. In OSCE’s this takes I can’t say I ever want to break up with someone 8 minutes, with ex-boyfriends this takes an hour again, but if I have to, I’ll do it with SPIKES. and we’ve still only spelt ‘SPIKE’.

This story is loosely based on the experiences of a ‘S’ is harder with exes than patients, I’ve colleague. It has been written and published with discovered. How do you create a strategy for your permission. Initially published on the Griffith University personal life? Apparently, you talk for another hour Medicine Society blog and adapted for PANACEA (https://gums.org.au/site/2019/04/16/spikes/)

and conclude that maybe in another life you would be a good couple but, in this one, you’ll only ever be Facebook friends.

SPIKES

an acronym for presenting distressing information to a patients and families

S setting P perception I invitation K knowledge E empathy S strategise

RICHEST MAN IN THE CEMETERY

by Kira Muller James Cook University, Year III

Decaying, rotting, Slowly, every day since our first bloom.

The Earth from which our roots hold firm Will want us back Life is only a loan.

With youth – there is beauty, But I can’t appreciate every rose With my nose deep in the spine Of an obstetrics handbook.

With what to measure Success?

As we vine our way up Ladders in the garden, Climbing with exams scores, HDs, Listing bullet points on our CVs, The closer we grow to the sun The worse sun burns our skin.

Or is success measured in late nights with friends, Cheap rooftop wine Laughter and paintings, Keeping score of the number Of books we have read To list proudly on our gravestone.

We live Between textbooks and ward rounds And the soft glow of our laptops at 2am.

We tell our sick patients To go home if they can.

Is there not irony In living In the house of the dying?

Remember what makes home So much better than the hospital, Next time you discharge a patient On the fourteenth hour of your day.

O, the many pathways through the garden All leading to the same destination.

We can’t stand at the foot of the beds With steths draped around our necks forever.

The world outside us is blossoming But my sinuses are overwhelmed.

How do we properly succeed?

How do we make this blip last eternity?

There was an Attempt Tales from first year medical school

by Brooke Carmody University of Sydney, Year I If there’s one thing that first year medical students can say they’re experts at, it’s making mistakes.

These mistakes are nothing to be ashamed of; in fact, they build the very foundation of the medical expertise we’ll presumably have by the end of the course. Failing is rarely spoken of in our field. It’s almost seen as taboo, as something that anyone even remotely associated with medicine could not possibly be capable of. I find it fascinating, as our mistakes as students are often quite amusing and make for great conversation.

Sometimes we only get better at certain skills by making gaffes that leave us wondering how we even got accepted into medical school in the first place.

Take for instance, a lovely summer’s day on the wards, where five overzealous, overtired and underprepared medical students were thrown into a patient’s room with no more instruction on how to take a history than “make SURE they know you’re a first year medical student.” It begins. We parade in single file, taking up all conceivable space in the room.

Nervous energy fills the air, as if none of us have ever spoken to a human before in our lives.

Who will be the first to speak? There’s five of us after all, surely not I? The gap between walking in and actually speaking is 2.4 seconds longer than socially acceptable. There is no clock in the room, but I swear I hear a second-hand ticking.

“Hello, I’m Brooke I’m a first year medical student, actually we are all first year medical students, we would like to take your medical history today but only if that is ok with you, also we are in our first year.”

A collective sigh as we break the ice, albeit I am mildly worked up at how awkwardly one could introduce a group of students. At least the patient should know we are, in fact, first years.

How can we recover from this, and is it still possible to maintain a façade of togetherness?

The patient responds; “you’ll have to speak up dearie, I’m a bit deaf.” Well it looks like we got a do-over.

We hear of these small embarrassments as often as we commit them ourselves. Try as we may to follow every history-taking guideline and examination procedure, the only way to learn how to adapt your own style is to, quite frankly, look like an idiot a few times. Whether it be your friend proudly announcing the heart is on the right side of the chest, putting your stethoscope on backwards and pretending to hear lung sounds, or being asked to interpret an MRI and identifying a lesion in the spleen (which would’ve been ok but the organ in the image was actually the liver); we only start getting to the right answers after making some absurd slipups. There is comradery in the fact that after the consultant leaves, we can all laugh as we realise in unison, none of us even know what the spleen really does anyway.

Through all of this I find most of my colleagues and friends are happy to fail as long as they made a valiant attempt. Perhaps the hand exam you just did looked more like an obscure clapping game, and maybe asking the 92 year old patient if his parents were in good health wasn’t the smartest move, but these are the stories we remember that remind us what not to do. There’s

nothing quite like presenting a history to the consultant, thinking you’d finally nailed it, for them to check the patient notes and say, “did she mention anything about the stroke she had last week?” No, she hadn’t mentioned the stroke, but you bet I got the down low on the appendectomy she had 50 years ago.

All of these moments could be considered small failures, but none of them are inherently bad.

Occasionally embarrassing, yes, but learning experiences nonetheless. These instances glued together will eventually form the foundations of the elusive moment of success we all see as a distant dream. I’ve already begun to see the results of our failings in practice. A moment of glee after taking an accurate set of vitals, a correct diagnosis, a genuine smile from a patient you made laugh. Success in the end is really just the sum of our mistakes; and until we get to the success part, “Hi I’m Brooke, and I’m a first year medical student.”

Dear Readers, I hope you enjoy this poem. I was inspired by one of my favourite quotes from Michael Jordan, “I have missed more than 9,000 shots in my career.

I have lost almost 300 games. On 26 occasions I have been entrusted to take the game winning shot, and I missed. I have failed over and over and over again in my life. And that is why I succeed.�

On Finding Failure Merryl Rodrigues Monash University, Year 3B

Finding Failure is now A long realised wisdom A leap towards growth Many celebrated winners Had routine failures I acknowledge all of this Yet I hate to fail Shame and judgement Prevails like the plague I fear failure Like worn ragged cloth, it appears distasteful Cause the world celebrates wins The world praises talent and intelligence The world casts a dimmer light On Relentless Failures Do wins outshine failures?

No Imagine if Edison stopped at his 9,999th try Imagine if J.K Rowling stopped searching for publishers Imagine if Michael Jordan feared taking a shot Like a painful cliche, The overstated truth Painfully persists in failures You hold the pen To shape the course of your failures The world is merely a spectator

On one of my down days, I seek help.

Anonymous Submission.

UNSW On one of my down days, I am like a car without a steering wheel… and on one of my good days, I just forget all about it and move on. So something breeds and breeds and eats me from the inside until it becomes bigger than my life, and I can push it down no further. What comes out of me thereafter is stuff like eating disorder, depression, insomnia, anxiety and suicidal thoughts. If not for this damning perfectionist, self-reliant, enduring, everything-is-awesome, everything-will-pass attitude, which has given me much success in life, but also much toil, I could’ve stopped this years before it became this big, this bad…

Now and then, especially when life slows down, or when the quietness of night creeps up, many of us visit a dark place. Do not ignore it! Please know that help is out there- your friends and family- someone will care.

Sometimes simply talking about it and acknowledging that ‘I am broken’ is OK and therapeutic on its own. The only time I was blown away by Justin Bieber was him braving in front of the camera, ‘I am human therefore imperfect’. It is the imperfections that make us us, that make life life, and all is understandable and forgiven. I encourage you to be kind to yourself as you would to a small child, and treat yourself, to an ice cream, to an afternoon of beach, to a long-awaited catchup with a friend, a long-awaited catchup with your GP, and a long-awaited appointment with a wellbeing advisor! You would be surprised how much your therapist can ‘break’ you, then ‘heal’ you and like broken bones, you’d be healed much stronger.

Recovery takes effort, it takes time. For me it’s like mopping up gallons of spilled milk, but at least the ground is drying up and I am no longer slipping.

There should be no shame in seeking help, and no judgement from others; if there is, it is shame on them, and they can be out of your life in a whiz!

A guy once stopped me from sharing my story with others, deeming it triggering and inappropriate. I suppose it is people like him who claimed to be ‘sensitive/protective’, who are in fact ignorant condoners of stigma around mental health, so that sufferers continue to suffer in silent tears, fear and fury. It doesn’t need to be this way.

Attitudes toward mental health can change, and are slowly changing, and better treatment and prevention for mental health illness can be achieved by encouraging and looking after one another. I hope especially that our medfam continue to grow in awareness and desire for mental wellbeing, and that there are leaders among us, who dare to make change despite resistance in society, and yield benefits that will last well into the future!

category is... growth

by Conor Cusack (he/him) University of Queensland

I am a white, gay cis-male. It is extremely important to note that my experiences growing comfortable expressing my sexuality and negotiating society as a gay man are entirely different to others; particularly the experiences of trans people, people with a disability, CALD people and people of colour.

Recently, I was abruptly confronted with a situation that, despite my comparatively significant experience in the gay health space, I’d never come across before. I faltered.

I was with a friend on a ward call shift shadowing a stressed junior doctor when, deciding I couldn’t take much more of staring at someone’s chart medications, I bailed to grab a hot chocolate.

Naturally, as soon as I left, they were called to a code. I downed the drink and rushed to meet them on the ID ward; on the way passing a middle aged couple standing awkwardly in the dimly lit corridor.

Walking into the patient’s room, I was immediately struck by how emaciated he was.

Being two med students in a code, my friend and I found a nice, out of the way corner from which we could watch everything unfold and my friend filled me in on what I’d missed. The patient was febrile, younger than us, and had been admitted via ED a couple days prior with FUO and covered head-to-toe in Kaposi’s Sarcomas. He weighed 36kgs.

Since his admission he’d been told he was HIV+. The couple in the corridor were his parents. He was terrified that they would find out that he’d contracted HIV and everything that it implied with regards to his sexuality.

For over a year, I’ve spent my Saturdays working at a GP clinic with a special interest in LGBT+ sexual health and HIV medicine. I regularly take histories, collect blood, swab throats (amongst other places) and treat STIs. While I’m not great with the vast range of antiretroviral therapies, I feel pretty comfortable performing routine check-ups for people with HIV. Despite my regular exposure to patients with HIV, I’d never seen someone in a florid AIDS crisis and had absolutely no idea how to react.

He started to cry.

Not because of the code, or the influx of people, but because he was scared that this would be the moment his parents found out about his sexuality.

Assuming I was the only other gay guy in the room I felt an obligation to do something. To sit by his bed and hold his hand. To tell him about the dozens upon dozens of patients with HIV from the clinic who live happy, healthy and long lives. To tell him that I’ve seen people coming from similar family situations either eventually be accepted by their own parents, or go on to build loving families of people they choose.

Instead, the best I managed was a pursed-lip smile when he briefly glanced at me. A woefully inadequate attempt at reassurance.

Eventually, we left the code. I went home to a Mum who unconditionally accepts me for who I am. I sought empathy from my friends, many of whom are proudly and openly gay.

I cried.

As future doctors, it is vitally important that we create a healthcare system that not only accepts LGBTIQ+ patients but welcomes and actively supports them. This experience brought home a couple of things for me; • The importance of understanding intersectionality and the social determinants of health. If you, like me, are a white, gay cis-man who’s struggled with bullying and adversity growing up, you might shy away from recognising the intersectional aspects of our community for fear it lessens your own difficult life experiences. It doesn’t. This is best explained by Roxane Gay, “You don’t necessarily have to do anything once you acknowledge your privilege. You don’t have to apologize for it. You need to understand the extent of your privilege, the consequences of your privilege, and remain aware that people who are different from you move through and experience the world in ways you might never know anything about.”

• Despite what some people think, the fight for LGBTIQ+ equality did not end with marriage equality. In Australia, there is absolutely no valid reason that this patient’s HIV status shouldn’t have been detected and treated early instead of progressing to AIDS. Given his fear, I assume he struggled with significant internalised homophobia fostered by an upbringing of intolerance and hate. This led him to deny the health risks he faced and prevented him from seeking help early when his symptoms manifested. He did the best he could with what he had, but unfortunately it wasn’t enough. Around the world, people are being imprisoned or murdered for their sexuality and gender identities. It’s easy to grow complacent when rarely exposed to the reality of what it still means to be LGBTIQ+ for many people.

Knowing this, what can we do as good allies and future doctors to improve the health of the diverse LGBTIQ+ community? Here are some suggestions that might be good places to start, 1. Realise that merely watching Drag Race, listening to Troye Sivan and going to a gay bar once a year are not enough to qualify as a ‘good’ ally or even an ally at all. As my friend and prominent advocate, Paige Wilcox says in her open letter, “... we’ve gone beyond the point of needing allies purely for visibility and social media likes. If you’d like to be an active ally and really make a difference, there are options.” You are not alone in this, I have had to acknowledge that to the diverse groups that make up the majority of my community, I am an ally and that this comes with responsibilities. One of which is taking a back seat and giving other members of the LGBTIQ+ community a platform when the opportunity arises.

2. The T in LGBTIQ+. It would be inappropriate and inaccurate for me to attempt to provide information about trans or gender diverse communities and their experiences. There are many resources and personal experiences online from which you can learn; you can start at the convenient link above. What I do think is appropriate to say, as someone who works with more trans and gender-diverse people than most medical students, is that despite a weird and persistent belief among medical students and doctors, you do not have some innate ability to divine when it’s necessary to ask people about their preferred pronouns.

You might think you do but you don’t, and carrying on with that attitude will eventually cause someone harm and it won’t be you.

The trans and gender diverse communities face many barriers in health care; things like ‘Trans broken arm syndrome’, being treated disrespectfully, the pressure to out themselves, discriminatory administrative forms and more. Postponing healthcare due to fear of all of these things can mean that conditions are more severe on presentation.

Creating genuinely accepting and safe spaces for trans and gender diverse people enables them to access healthcare just the same as any other patient.

3. If the curriculum your medical school uses to teach about LGBTIQ+ issues is outdated, discriminatory or unacceptable - challenge it. As an ally you can approach issues in a way that LGBTIQ+ people inherently cannot.

LGBTIQ+ people are automatically forced into a position of vulnerability when asking others to tolerate them. Hearing incorrect or misleading information as an LGBTIQ+ medical student puts you in the position of either allowing that misinformation to persist, potentially tainting the clinical interactions of peers with your community, or out yourself and adopt the role of an advocate to provide the correct information. No member of the LGBTIQ+ community is under any obligation to be an advocate for their community or a source of information by virtue of their sexuality or gender identity. Additionally, recognise that many of the people involved in biomedical research and medical education have their own biases, conscious and unconscious, that influence how they portray issues. Be critical of what you hear and read, and draw your own conclusions.

4. Finally, learn about sexual health, preand post- exposure prophylaxis, and U=U. Contrary to what medical education suggests, the LGBTIQ+ community is about vastly more than just sex and sexual health, however this is an area consistently handled remarkably poorly by doctors, leading to poor patient experiences with future implications for how they access healthcare. You should be able to take a sexual history as easily and fluidly as you would take any other aspect of a history. You should be fully aware that the standard blood screen and a urine NAAT for chlamydia and gonorrhoea is rarely sufficient for an STI check for any patient; that PrEP is a safe and effective way of preventing HIV in people at risk, and that people with HIV and an undetectable viral load on treatment cannot transmit the disease to their sexual partners.

Pride month is an amazing time of year where the colour and vibrancy of our community is on full display and I strongly encourage all LGBTIQ+ people and allies to get amongst it, particularly if you’re newly out of the closet. Listening to the wealth of knowledge our LGBTIQ+ elders have to share about the adversity they faced and recognising their role in moving us forward is vital to our collective story. For allies, we welcome you to appreciate the art and culture of our community whilst remembering that this is a relatively new experience for many LGBTIQ+ people. However, it’s fundamental to remember if you want to dance with us when we celebrate, you need to stand with us when we face adversity.

“If you want to dance with us when we celebrate, you need to stand with us when we face adversity.”

Conor Cusack is a final year medical student at UQ, the Co-Chair of the Queensland Medical Students’ Council, and a weekend medical assistant at Gladstone Road Medical Centre, a leading practice in the Qld LGBT+ healthcare space. He’s a proud member of UQ’s Rainbow Med and QAMSA, AMSA’s Queer Network, and readily approachable by any LGBTIQ+ medical students seeking support and guidance on what it means to be LGBTIQ+ in medicine.

E: conor.cusack@amsa.org.au Editors Note: This piece was originally published as a feature in AMSA’s monthly newsletter ‘Embolus’ for Pride Month; June, 2019. It has been republished in Panacea with permission.

NLDS’19 Event REport

by Matthew Kim NLDS Event Convenor University of Queensland, Year IV From the 11th to 15th May, over a 100 students from across Australia and New Zealand gathered in Canberra for the immersive experience of AMSA’s National Leadership Development Seminar. Across these 5 days, delegates learnt from some of the country’s finest leaders, applied their theoretical knowledge in teams to translate ideas into actionable reality, and shared views to foster new networks along their medical school journey. Above all, NLDS 2019 spurred delegates to seek passion for inspiration as the catalyst to further their path as leaders in their own right.

We opened NLDS at Ainslie Arts Centre, a heritage-listed building adapted from its previous life as the Ainslie Public School, the first primary school in Canberra established in 1927. Over the ensuing days, NLDS lived up to its reputation as AMSA’s premier academic event, creating an intimate environment for delegates and speakers to interact. From Dr Yumiko Kadota and Dr Jessica Dean to Professor Peter Doherty and Dr Tony Bartone, we were privileged to hear our many speakers’ insights into leadership and the important lessons they had learnt as leaders in their field.

To complement such breadth of experiences, delegates were divided into teams for NLDS Projects, each being tasked with building a pitch to address a particular societal issue that affects the medical profession. Improving engagement of medical students in refugee and asylum seeker health advocacy, reducing burnout amongst medical students, and raising awareness of climate change are only a few topics encountered by our delegates throughout NLDS. The culmination of such incredible teamwork led to the Projects Presentation, held at Old Parliament House.

Of course no conference would be complete without its fair share of social events, and I am confident in saying that every delegate left Canberra with new friends and exciting opportunities for collaboration to look forward to.

Every year, NLDS strives to produce an empowered cohort of medical students who will wield positive change in their community.

This year, we have truly tested our capacities to create the right environment for our delegates, maximise their upskilling opportunities, and foster greater understanding of their unique brand of leadership. Overall, I am happy to say that as a team, we have succeeded.

Yet it was, and could never have been easy, and finding failure is hardly an enviable task.

Yet identifying errors to understand mistakes is universally one of the best tools to improve for next time. NLDS embodies this notion of self reflection. A recurring motif amongst our many speaker presentations and what appears to be an indispensable facet of leadership is the ability to reflect on failure, honestly and genuinely. On reflection of my experiences over the course of a year as Convenor, I could not agree more.

There are many people to thank for the past year.

Thank you to members of both 2018 and 2019 National Executive as well as the Board, namely Alex, Jess R, Jack, Vru, Jess Y, Clare, Hannah, Madeleine, Shyamolie, Gavin, Haydn, and Adrian for all your invaluable help. Thank you to our 108 delegates for whom this was all for. And thank you to my wonderful NLDS 2019 Family - Haleem, Marissa, Casey, Jasmine, Sam, YiJie, Issy, Wis, and Tez - for not only putting up with my antics but more importantly, for the teamwork, the memories, and your passion in creating this fantastic event.

Vampire Cup 2019 REport

with an incredible 79.3% of their cohort donating to our cause! Also, coming in a hot second with 75.4% James Cook University has continued their success from 2018 and become the most successful university ever, in terms of raw donations securing 845 individual donations in total! Winners of the most improved university this year are Griffith University who increased their total number of donations by 173% from 95, in 2018, to 259 this year!

by Corinne Antonoff Vampire Cup National Coordinator University of New South Wales, Year IV

This year in collaboration with the Australian Bone Marrow Donation Registry we have focused on encouraging registration to the bone marrow registry. This part of our campaign received some amazing feedback and if you would like to learn more about bone marrow donation or how to sign up visit the Vampire Cup website (https:// www.amsa.org.au/vampire-cup).

Vampire Cup finished on the 31st of May after 8 weeks of fierce competition from medical students all around Australia. If you haven’t heard of us, Vampire Cup is AMSA’s National Blood Drive which is run annually with assistance from the Australian Red Cross. We have local representatives from each of Australia’s 22 medical schools who put an enormous amount of time and energy into running local campaigns and involving their student body in the race to save lives!

After an even earlier competition than last year, we had a phenomenal year with 3461 total donations which makes this year’s Vampire Cup the biggest (and bloodiest) ever!!

Moving the competition to the beginning of flu season was our way of helping to boost stocks just before winter in a crucial time period for the Red Cross. Even though our competition ran over Easter, our donation numbers speak for themselves and are a testament to all the students, friends and family who gave up their time to selflessly donate!

Congratulations to our overall winner the Australian National University who triumphed

Finally, Vampire Cup also had donations from 685 amazing people who rolled up their sleeves for the first time! Thankyou to each and every single donor who entered our competition; each university put in an amazing effort but, at the end of the day, Vampire Cup is about educating everyone about the importance of blood donation.

We hope that by spreading the message about the importance of blood donation we will not only help save some lives but also help reinforce the message that blood donation is important all year round (not just during Vampire Cup!).

Vampire Cup will also be collaborating with DonateLife to promote organ donation during DonateLife week from Sunday the 28th of July until Sunday the 4th of August! Keep an eye out on the AMSA central page and, if you haven’t already, please consider signing up to be an organ donor!

Each blood donation saves 3 lives, so if you can, donate today! Your efforts will not be in vein!

PANACEA POP QUIZ! Courtesy of AMSA MedEd Test your medical knowledge with these three questions! Answers are on the next page.

All questions and more are available on the AMSA moodle at http://amsamoodle.org.au/ Q1. Jamie is a 19-year-old student who attends the Neurology clinic today. She has attended because there has been an increase in frequency of her headaches. Jamie has a history of recurrent, severe headaches that can last up to 24 hours, up to 2 times a week. They are associated with nausea and occasional vomits, and worsen especially with exposure to bright lights.

In the last week, she has had a constant headache without any headache-free time in between. She is most concerned because it has been affecting her attendance at University, which she has been unable to attend as she has been bedridden.

Jamie has tried paracetamol and ibuprofen to no effect; her family doctor had prescribed her some codeine which she has been taking almost every day for her headaches, which are not getting any better.

Her observations today are as follows: BP 120/60, HR 80, Temp 37c.

What is the best management option you can offer to Jamie?

A. A triptan (e.g eletriptan, sumatriptan) B. Propranolol for prophylaxis and a triptan for acute attacks C. Amitriptyline D. Advise her to wean and then cease codeine E. Do a CT Brain or MRI to exclude brain tumour Q2. A 66 year old man re-presents to his GP with intermittent back pain that has been frustrating him for the past 6 months. The pain stops him from doing his gardening, which is primary source of joy in his retirement years.

He has had a recent diagnosis 8 months ago of prostate cancer which was resected with clear margins.

The surgery was uncomplicated, however since yesterday he has felt numb around his genital area and has had multiple episodes of incontinence. He worries the cancer is back. Last time you saw him 2 months ago for this pain you ordered an MRI which showed no abnormalities.

What is your most appropriate next step in management?

A. B. C.

D. E. F.

G.

Perform a DRE and refer urgently to his urologist Perform a DRE and refer non-urgently to his urologist Organise to see him next week to reassess, encourage regular paracetamol.

Repeat MRI and see him for the following day Refer urgently to ED Explain the pain is most likely musculoskeletal and refer to a physiotherapist for strengthening exercises Refer to an occupational therapist for advice on devices to assist in gardening

Q3. Will is a 24-year-old male who presents to his GP complaining of a sore throat, cough, and changes in his urine. The sore throat has been around for approximately a week, and his urine turned “the colour of tea” yesterday. His Anti-streptolysin O titre comes back negative. Suspecting a certain diagnosis, you begin the process of organising a renal biopsy for Will.

What can you tell Will about this likely diagnosis?

A. B. C. D. E.

He can expect hearing loss and visual abnormalities to eventually occur His anti-dsDNA antibody will likely be positive It is a type III hypersensitivity reaction It is caused by deposition of Antigen-IgM complexes in the glomerulus There is a 60% chance he will recover completely

ANSWERS: Q1. Answer - D. Jamie has a medication-overuse headache, from using too much opiate medication.

This would fit with her clinical picture of worsening headaches, to the point of transitioning from episodic migraines to chronic migraine.

While giving any of a triptan/propranolol/amitriptyline/metoclopramide (answers A, B, C) are all safer and potentially more effective treatment options than her current medications, the first step towards managing Jamie’s chronic migraine is stopping her opioid overuse. After this has been ceased, we can suggest options for acute management such as triptans and prophylactic treatment with propranolol or other medications.

A MRI or CTB is not indicated in investigating migraine (answer E), and the clinical picture is highly suggestive of migraine due to its chronicity - excluding pathology such as meningitis (she is also afebrile) or brain tumour.

Q2. Answer - E. While there are multiple issues at play here, this man presents with acute onset saddle anaesthesia and urinary incontinence which is likely due to acute cauda equina. This is a surgical emergency and should be referred to ED. His cauda equina could be due to a metastasis of prostate cancer, acute disc herniation or another unrelated cause. Referral to urologist, repeating the MRI, encouraging physio and OT advice are reasonable choices if cauda equina has been ruled out.

Q3. Answer - C. Given the history of a young patient with a possible Upper Respiratory Tract Infection in the context of macroscopic haematuria, IgA nephropathy and Post-Streptococcal Glomerulonephritis are important differentials. The negative ASOT titre points you away from PSGN, so you’re thinking about IgA nephropathy.

A: This is typical of Alport’s syndrome, which this patient is unlikely to be developing now and with

no strong family history.

B: This would indicate Systemic Lupus Erythematosus, which is unlikely given his lack of other

symptoms and with an ‘initiating event’ of an URTI C: IgA nephropathy is a Type III hypersensitivity reaction caused by the deposition of Antigen-IgA

complexes in the glomerulus D: Unfortunately, IgA nephropathy is caused by IgA deposition, rather than IgM E: There is only a 10-30% chance that will recover completely, as most patients have some persisting

or later-onset of renal dysfunction secondary to IgA nephropathy.

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