This tiny moment

I’m back on ward service, consulting as a geriatrician. I write this tonight so I can get it off my chest and go to sleep, otherwise I’ll think about it all night. I saw a patient today with terrible, terrible, distressing BPSD. No one could get near her. She tried to end her own life, threw equipment. When I went to help, it was almost like a terrible painting. Black-clad security guards, covered in equipment, nurses, a doctor holding up a syringe. Everyone in masks.

I pushed past them all. They warned me off but I pushed past and just put my arms around her and held her tight and she held back for the longest time and just started crying and crying. I could feel her distress in my bones. I know that distress now. The worst of all nightmares, except she was living in it. We sat for the longest time. She gave me one of her bracelets, would not hear of me giving it back (later I slipped it back to the nurses, to lock in her drawer, much as I wanted to keep it to remember her, this moment). We held hands in this tiny moment. Something happened here. I’ve never done that before, it’s not even safe to do that, but something happened. I don’t even know what it was. Some part of me recognised her and some part of her recognised me as safe. I wonder what it must of looked like, two small women hugging each other in corridor, surrounded by masked security and medical staff. I want what this tiny moment even meant. Because it felt too special for words me. But I have to capture it in words, so it lives on here, and so I can sleep. I wont ever forget her.

Dementia is a terrible disease and I hope we find a cure one day.

The Merry Go Round.

I was looking for WordPress but typed in Blogger by mistake. I found some more of my old blogs (there’s 10-15, one day I should collate them) and found a post from where I was a medical receptionist sitting the GAMSAT, complaining about people complaining about the Medicare out of pocket. Which, in 2005, was $10.

What struck me was how cyclical everything is. Not just birth and death. Everything. Trying for something, failing or succeeding, starting over regardless of outcome. The dumpster fires of our lives, leaving trails of destruction. The clean up after the storm. The slow return to whatever normal was, but isn’t now. The merry-go-round you can’t opt out of. And if you’ve socially conditioned into being an emotionally reactive people pleaser like myself, you’ve added loads of things onto that merry-go-round until it doesn’t function properly, and the clean up after the storm is all about not taking on the seeming one-off opportunities that definitely don’t come up repeatedly in this field (except that they do).

The merry-go-round is you. And the intrinsic worth of that ride isn’t defined by the things you add to it. The intrinsic worth is all in how well you take care of it. It’s taken a cancer diagnosis to finally see that and it stings reader, it really really stings. When your worth stops being defined extrinsically, suddenly all the things you were doing lose their meaning. Sitting in clinic trying to focus on something you’ve ultimately chosen for reasons that don’t resonate anymore is hard. Watching your colleagues ascend and ascend and feeling one part jealous and one part lost because now there is two yous, the before you and the after you, is hard. If I’d had good instrinsic self worth from the start, how much of this life would I have chosen for myself? And now that I am here, how do I choose anything at all, for the future? And survivorship means its hard to plan for a future you now really know was never guaranteed. It’s easier to be blind to that.

Anyway it’s nice to finally feel like writing again. I’ve been slowly extracting myself from social media because the opinions of absolute strangers are meaningless to me now, and no foreign policy is going to be helped by faceless hordes. Journalling has become a bit of a buzz word, but in my darkest times it has helped. I have too many journals going on at once but they all serve a purpose. Like Taylor Swifts pens. I have my deepest darkest. The day to day record. And now, this one back. The longest thread of my life, the journal that helps me hold onto myself and who I am, what I care about.
I’ll be shocked if anyone is still reading but if you are, hello! And thank you!

Yikes.

13 years on this platform. I think. Getting on for two years since I posted. Both my kids in primary school. And now for the latest plot twist, recovering from a cancer diagnosis. I don’t want to write too much about it. It is as shit as you would imagine it to be. I’m almost on the other side of treatment, ready to be released back into the world, hopefully with no evidence of disease.

And for the first time, I don’t really know what to say. I don’t feel like opining on anything because so much has happened. How to even find the words to process? Yet that’s what blogging always was for me. Anyway I just wanted to write and say hey, I’m still here. That erstwhile intern is now a boss and well, that’s weird. Time passing is strange. In your head you’re often that intern, but with all the experience of a consultant. And I got that public hospital job. And I find myself itching to do my juniors work for them, but you can’t because they don’t learn how to do it. You just have to be…there. Guide. Guide some more. Take the heat when shit hits the fan. Get it wrong. Getting it wrong still stings and I don’t think it will ever stop stinging.

And having cancer has just made me even more frustrated with the system. You have half an idea as a doctor…but far out, as a patient? More on that…eventually. When I have the words.

But for now, hi.

Easier.

“It doesn’t get any easier you know”.

Words ruefully said from a consultant on the precipice of retirement, to a registrar on the precipice of their career. I didn’t understand at the time. Surely it got better. Anything was better than being a registrar to me at the time, post exams, exhausted from night shifts, babies, endless demands. But now that I’m deep into my first year of consultancy I’m beginning to understand. In medicine, someone always wants a piece of you. Or, they don’t want you at all and will tell you so. The demands are endless, the rejections searing. And he was right. (Although it’s still better than being a registrar, I can promise you that).

You go through medicine with this deep and unconscious desire to be wanted. You will do anything to be wanted. Join committees, do research papers, work long hours. You want to be wanted by your consultants, your patients, your colleagues. And the system reinforces this by making you reapply for the same damn job, year after year. And then you finish, and the worst thing happens. You’re unwanted. You disappear from being the centre of everything. Everyone still employed by the hospital keeps on with their day, and you fall into that black hole of just another registrar passing through. Unconsciously, or maybe even consciously, you put up with so much as a trainee, because somewhere in your mind, you hold that coveted position of the ‘boss job’ so dear. And everyone knows of a golden child registrar who sails straight through into that coveted role and everyone builds it up, tells you to invest your self esteem in it. But it’s a mirage. It’s so incredibly rare. Most people don’t have that experience. And people will try to tell you this, over and over, but you wont listen. That won’t be me, a small whisper inside of you says, I’m special.

In this game, none of us are special. The hospital system is not your family and it is not your home. What has happened is that you’ve overinvested in it and you’re in for a big letdown. And the best, and the worst part is, is that this needs to happen. You need to know. You need to really really know just how unimportant to this system that you are. Because once you do that, you get your life back. Once you really know, you wake up one day and realise that you don’t have to feel guilty for doing nothing. You don’t need to treat having a hobby like it’s a special treat. Or time with your kids. Or making time for your kids. You don’t have to die, over and over on the sacrificial altar of medicine anymore. You get to have a life. Those rare, golden children, rarely realise that until it’s much too late, or never. The whole system, being run by politicians, relies on good will to run. And it pushes us all into thinking we are never enough, never good enough, never enough to be wanted. We are all incredible and dedicated people. When you are finally released from this place, out into the community, everyone needs you. Everyone wants you. Everyone thinks you’re amazing. And the difference between the two places becomes ever more stark. Suddenly medicine becomes less about administration and patient flow, and becomes about the patient and their family. Suddenly you find yourself focused on their needs, and their story, and all the rest melts away.

If I could give my past self a piece of advice from the future, it would be this. Don’t hold out for a public hospital boss job. Look past that. Hold out for the sort of life you want to live and the free time you want to have. Ask yourself how you can make your newfound freedom work for you. The BEST thing I did, was join a private practice that lets me work as much or as little as I want. And in having that freedom I began to rediscover who I was outside of that system, and what I liked doing. The money you earn enables you to live the life you want, and more importantly to enjoy it. Private land is barely even whispered about in the public system – partly because those working privately don’t want others to know how good they’ve got it, and partly because those who’ve never worked private are terrified by the concept of it. And so, while I might be restarting back in the public system shortly, this time away from it has given me the gift of disinvesting my self esteem from it.

Wherever you are in your training, no it does not get easier because life just doesn’t. But it DOES get more rewarding. And you do get more control of your life when you finish, and I’m glad I did.

The other side of training.

Congratulations if you’re still following after a near 2 year hiatus. Got stuck in a pandemic. Finished training a few weeks ago. Starting as a geriatrician in private practice in a few days.
So I know you want to know, what’s it like? What’s it like NOT BEING A JUNIOR DOCTOR?

At first it’s horrible. You’re so institutionalised you don’t know how to come out of your cage. You feel like a failure because you didn’t secure The Greatest Boss Job of All Time at The Most Prestigious Hospital (even though you’re not sure you wanted that anyway) even though there are no jobs because pandemic. And then as you get to know the new private practice you’ve just joined, who’ve been encouraging you to come on board for almost the last three years, you understand what life can be like. Your life belongs to you. You get asked questions like “what hours would you like to work?” and “we’ve sorted out all this stuff for you” and “we’re here for you”. Your life is your own now. Yes there’s still college requirements but they don’t require the begging and silent shame of never getting them done on time. People ask your opinion. All that struggle was suddenly worth it.

And here is the greatest kept secret the public hospitals don’t want you to know. Private work (which lets face it, is hardly American style billings and you’re going to bulk bill a lot anyway), is lovely by comparison because you’re in control of you. No more yearly distress over having to reapply for the same job you’ve been doing for years. No more being barked at by hospital admin for minor transgressions. You’re just simply, free. Keep your eyes on the prize trainees.

This is what burnout looks like.

1. Crying in the car to and from work
2. You can’t think straight
3. Feeling really disorganized and like your notes make no sense, your handwriting is too messy etc.
4. Thinking everyone can see you’re not doing a good job.
5. Feeling like work is a relentless onslaught in which you can never do the job well enough because the patients just keep coming, and coming, and coming.
6. Struggling to remember things you could remember before.
7. Feeling super tired no matter how much sleep you’ve gotten
8. Worrying you’ve got horrible illnesses because of the above symptoms
9. Constant headache that just doesn’t go away no matter what analgesia you use
10. Wanting to exercise but just not quite getting there
11. Or overexercising into burnout then doing nothing for weeks.

This was me once.  If it’s you, go and see your GP, and organise some annual leave immediately.

1 year left.

It’s a really disorienting feeling being this close to The End.  I feel like I have vertigo.  I get a new resident and talking to them realise how far I’ve come.  In my head I feel like a resident half the time, so, so much to learn – but then I get a new one and I realise how much I have to teach (in a good way).  And every now and then I realise the conveyor built this is. This week I hit a point of realisation.  I’ve been tying myself up in knots about getting a boss job and suddenly woke up to the neverendingness of this.  The constant game of trying to impress.  We did it to get into med school, training programs, job interview after job interview, every year.  And it doesn’t seem to end when you become a boss (in the public system anyway), it is the constant performance with almost no time to rehearse.  Negative time if you have kids.  I don’t want that anymore.  I’m so tired of dancing to someone elses tune.  Of the endless rotation of what defines ‘good at your job’ which is hospital dependent anyway.  And at the same time I fear leaving the public system because that’s where your relevance as a doctor lives while you’re in it.  There’s almost no information as to what lies in the great beyond.  All I want really, is to take care of my patients, and do a really good job of it.

Final year.

***Warning:  this post contains confronting themes including domestic violence, traumatic death, and bullying.  Details have been altered to protect the patients***

On Monday I start my final year of training.  It’s surreal that I’ve been writing this blog since my final year of medical school, albeit increasingly less frequent over the years as other commitments have taken over and I’ve often lost my words.  Something happens to you towards the end.  This rising tide of anger at all that you’ve been through, something inside you just wants to quit right before the end, burn it all to the ground.  You say things like “back when I was an intern”, even though when you were an intern you hated that.  And you tell stories about your internship and beyond that seemed perfectly normal to you, but through the lens of the post-bullying, post-metoo world, were actually really traumatic.  And then you realise just how very much you have supressed over the years, when you start telling your resident about a rotation and suddenly the things you had forgotten roar into your consciousness.  And you realise you barely processed them at the time.

To the lady broken and bruised all over from years of domestic violence, finally ready to leave, you are a hero.  I’m glad he went to jail and I hope he’s still there and that you’re okay.  To the guy in his forties who died of tumour lysis syndrome in front of me while calling for his mother, I’ve never forgotten you.  To the lady who died with her lungs filled up with cannonball mets, who had a small child, I’ve never forgotten you.  That nice lady with fevers who had a lung filled with MRSA that was picked up a day too late, I can’t think about you without tears, even though it was 8 years ago.  To all those kids with ‘adult’ cystic fibrosis, I wonder if you’re still alive, if you were responsive to ivacaftor and friends when it came in long after I’d moved on, I wonder if your lives are better now, if you’re still alive now.  To the guy who nearly bled to death in front of me, when I’d been made to work 24 hours straight as a second term intern, I hope they fixed it.  To the young guy crying in pain from liver mets, when I was too junior to understand that you would die that day, I hope you weren’t in pain when you finally went, and to this day I feel the sting of realisation that you were going to die that day, so young  To the beautiful husband of the lady that died suddenly, who we couldn’t contact because you were too poor to have a phone, I have never forgotten the heartbreaking grace you displayed when you arrived that day.  To my darling indigenous uraemic renal patient who I know must no longer be with us, you made me love medicine.  To the young man whose life was destroyed by tuberculosis, no one ever quite believes me when I tell people your story.  To the racist aggressive guy who abused the nurses, I have never regretted telling you I would chuck you out if you tried that again.

To the man who died because the system broke down, I can hardly think of you without suffocating.  You deserved more time on this earth.  To the little boy who became the first and only child I had to break bad news to, whose mother who had turned her life around and was dying before you, I hope I didn’t fuck it up, I had no training and I did my best.  I hope you’re okay and surrounded by love.  To the lady with the massive saddle PE who got me at my most junior running the arrest, I’m glad you lived.  To the lady with pneumonia that wasn’t pneumonia who wound up on ECMO, I prayed silently during every single ward round when we saw you.  I saw the religious icon in your room and I prayed to it.  I still don’t know who it was.  To the man crying in the emergency department as he died of a heart attack, I’m sorry I didn’t fight harder to get you the midazolam faster.  To the ED Registrar who heard me questioning your ability to read an ECG after a horrible arrest, I’m really really sorry.  I was out of line and I’m mortified at my own behaviour until this day.  I was traumatised by what I saw that night and I didn’t realise it – I hope you’re ok.  

To my renal patients, each and every damn one of you, I will never, ever, forget you or your faces.  And you June, I will never forget you, telling me to just be as I am, no matter what.  That you could be so giving, so kind, even though you must have known.  And to C, I looked after you for three months and because the night doctor forgot to tick a box, had to pull you out of the fridge in the morgue to certify you and I’m so sorry.  Neither of us ever wanted that.

To all the consultants who have berated me, locked me in dark rooms, threatened me, bullied me to ‘make me better’ – I hope one day you get the help you need and realise what decades upon decades of built up and pent up vicarious trauma has done to you.  I am not better because of you, I am better in spite of you and I will never, ever, be you.  To every single workforce administrator who bullied us via the rosters, who threatened our jobs, who weren’t there when we needed you – your time is up.  To the new age ones who listen and roster appropriately, thankyou.

I could do this all night, I have so many more memories of it all.  I’m currently at the loveliest department, on the loveliest campus in the world.  And yet I walk around it, constantly on edge, waiting for the other shoe to drop, waiting for someone to find some fault, for a horrible horrible arrest to happen.  And it doesn’t.  But every day, echoes of those experience follow me around, burn me out a little, even though the real burnout is long gone.  Every time the supervisor report comes around, little memories spring up, the dark room, fear the responses out of proportion to my performance spring up and I wonder how badly I’m going to do.  And every time I do really well, and every time I don’t see what they see.  I still see that intern, failing cannulas, being berated at the weekly meeting in front of an entire department for not using the right ICD10 codes, standing helpless in front of patients dying from diseases that are long past the window for cure, if there ever was a window at all.

And as I walk into this final year, slowly I start to realise why most consultants aren’t full time anymore.  I start to realise just exactly why there is no shame in walking away from this, of going to the community where you have the most opportunity to make a difference.  To prevent these situations, to have those crucial discussions that protects our patients dignity and quality of life.  I don’t ever want to completely leave, but it’s been a long long road and reliving all of that, by working in all of that for decades is something I’ve realised I don’t really want.  I do want to heal from all of that, and for that reason this year is all about that, of letting it go, of doing the rest of my life on my terms, whatever that looks like.

On being a healer.

If you’re an idealistic sort of person, applying for medicine is all about helping people.  It’s that vocational calling, not really rooted in anything rational, just this deep desire to connect with people, and help them in some way.  You know it’s a calling because when people question you on it, tear you down on it, laugh at it, tell you that it is not as valid a reason as loving anatomy or physiology, or science in general, it holds up.  It just holds up anyway, in the face of all that because that’s what conviction is.

Now nearly ten years since I finished medical school, I think a lot about what helping people really means, especially in that strange paradigm that’s a public hospital, that place of a million competing interests, not all of them patient-centred.  I watch as we treat illnesses, as the numbers recover, their colour returns, I call their families and try as best as I can to set the tone and make sure there are no surprises.  I try and keep their spirits up by telling them it’s going to get better, that home awaits,I thank them for their patience – I was in hospital for 4 days after a baby and practically self discharged, they’re in for weeks and rarely complain.  And then I learned that people with delirium frequently develop PTSD.  The things they see and hear, none of them rarely good, remain as memories.  We don’t talk too much at work about people might be feeling, if not only because the whole thing is so overwhelming for most that they don’t even know how they’re feeling until it’s all over.

The first time I ever thought about doing medicine was when I was 15.  I idolized my Dad and thought I could become a doctor like him.  When I asked him about it he just looked at me sadly said “oh my darling, you don’t need to become a doctor to be a healer”.  At the time I took it personally – did he think I wasn’t good enough?  And it took me a very long time to understand what he meant.

Healing is much more nebulous than treatment protocols for diseases.  It’s not in that bag of IV Ceftriaxone.  It’s not even necessarily your patient.  It’s their families, it’s you, your colleagues – everyone around you needs healing in some way or another.  Healing is that moment of “everything’s gonna be okay” that you feel when you wake up and aren’t sore or that terrifying fear you had is unfounded.  It’s when the air is warm after a long winter and your body relaxes and stops using up so much energy to warm itself.  It’s in that moment in a family meeting when you say “let’s stop for now, that’s a lot of information and these times are just so hard on you all”.  It’s the look on someones face when you validate how shit everything is right now, and that while you don’t have all the answers, you’re right there with them.  It’s in compassion and kindness and friendliness and reassurance, in those warm moments when someone says “hey I get stuff wrong too” instead of the cold “I’m perfect and obsessive” or when you sit down and just listen instead of telling someone you have to go because you’re so busy.  It’s in relaxing in that mire of hospital-anxiety and doing it your way instead of the way you’ve conjured, that correct ‘this is what a doctor is supposed to be’ that you try to shoehorn yourself into in spite of it being the antithesis of you.

Healing is all about you.  Healing is treating yourself with that warmth and kindness and friendliness that seems so absent sometimes and realising that in doing that, you’re truly helping others because the way you treat yourself is ultimately the way you wind up treating your patients and colleagues.  But more than that, it becomes the way you treat the people in your life.  And in doing that, you’re more than someone who helps someone, you’re someone who heals.  As a doctor, if you can be both that person who can manage the illnesses well, with a degree of knowledge, competence and confidence, and in addition, be someone warm who validates their suffering without having to be told.  Be someone who is endlessly kind and collegiate to their colleagues and doesn’t try to ‘teach them lessons’ by rejecting their requests, or belittling their missing details, instead offering to help them find them, or gently suggesting where, then my wonderful reader, you are both doctor and healer.  I see these colleagues from time to time and they are something very special.  The specialness comes from the kindness you display to everyone around you.  Don’t discount it, don’t let it be discounted by those who don’t understand it or are so far behind you on the path that they see it as weakness.  Let the best part of you come through in spite of that noise, you and your patients will be better for it.

None of us are getting out of here alive.

Dramatic no?  But as much as we might rationalise it, that’s medicine.  I’m PGY a trillion now, but strangely enough, Friday was the first time I’ve ever had to tell a perfectly cognisant person that they were going to die in the next few weeks to months.  Seriously. I’d never done it before.  I’d told family after family, held their hands and passed them tissues, made cups of tea many times over.  I’ve done actor training on breaking bad news, and then more actor training, and then more actor training.  And then some more.  But every single one of those training sessions was on breaking it to family.  Never to the patient.  It’s not something we are taught to do.  And in the public hospital system I’ve noticed it is something very much not discussed and hugely shied away from.  Sure we discuss with each other that someone is going to die.  We talk about the ‘futility’ of certain testing, of changing our approach, of discussing it with the family (but only once palliative care or geriatrics tells them to!) but to their face?  An elderly person?  When on earth do we do that?  Most of the time people are too unwell to be told.  But not this time.

I wont lie, I put it off for a week.  My resident and I talked it over and over and over.  My boss offered to help me.  I’m ashamed to admit I was too proud and declined and I bloody well should have let her show me how it’s done.  The problem was that we really like our patient.  She’s been with us for weeks.  And she’s going home soon anyway.  But she’s reached a point where the unique diseases that she has means they can’t be treated anymore.  And in the state I work in now, all the specialist services seem to operate almost solely in an outpatient capacity and tend not to have those discussions anyway.  I miss Sydney for this reason, I miss the absence of general medicine (apologies to my gen med colleagues, it’s just my normal).  I told her family first.  Secretly I was hoping they’d do the old ‘don’t tell my parent they’re dying unless they ask’ thing – but they didn’t, and finally after procrastinating so hard I couldn’t even look at myself anymore, I took a deep breath, walked into her room, pulled the curtain, and sat down JD style and told her.

I framed it in the way I’d done all the actor training, the words slightly altered.  “Oh no”, were her first words.  And then she cried.  She asked me if I was sure nothing more could be done.  I told her I was sure, that when it came back, we would treat her anyway, but it was unlikely to work, but we would treat her.  “Oh please“, she said, “Oh please try”.  She cried some more.  I cried a little too, but only for a second because she reached her hand out to me to comfort me and I realised, this was her sorrow, not mine.  I should be comforting her and not the other way around.  I fumbled around with my words, told her that this was going to happen to all of us, that we would all meet again one day, in one way or another.  And that right now, in this moment, the disease was surprised, right now she was as well as she could get and I didn’t really know when it would come back.  It could be weeks, or months.  She admitted she thought about dying all the time, and then the wave of grief subsided and she asked if she could be left alone to watch TV.  I gave her hand a squeeze, quietly left, and went back to the nurses station where I, the resident, and the NUM all cried because she is such a kind and lovely patient who we’ve grown attached to.

But now, as I write this, I feel an anger at the nihilism in medicine.  Especially toward the elderly.  I face it every day.  We take patients rejected from private hospitals and public rehabilitation because ‘too old’.  I get archly told by doctors senior and junior to me that a test is pointless, a treatment, because ‘what would it solve’, ‘what is the goal here’, because they never see the face of a patient asking, ‘oh please, just try’.  They never see their family saying ‘we know they’re going to die, but we just want to know’.  I get the same people waxing on about ‘costs to the health system’, like they are both the bearers and managers of that cost, forgetting in those moments that they are doctors and we are here for our patients first and foremost.  They never say these things to their faces.  I’m not arguing for a heart transplant in a 90 year old.  But one more trial of antibiotics, a brain scan, an arthrocentesis – none of these things are big asks, but they bring a lot of peace of mind.  Once you know, as a person grieving, either for yourself or a loved one, that everything that can be tried has been, once you know the hard diagnosis, instead of the presumed one, plucked from the air with the certainty of the ignorant, you can accept your grief.

My patient has children.  Grown children.  Grandchildren.  And she’s not done yet.  She’s not ready not to exit from their story, or her own.  As much as I can help see as much of the rest of her life I will.  As much sadness I have for her story as it is now, I’m also humbled by that conversation because in that tiny amount of time, I became a vastly better doctor.