Guts and glory.

I’m doing an outreach rotation at the moment.  It involves venturing into the community, leaving the bubble of the hospital, and assessing people to see if they need to go to hospital.  The idea is that if we can treat them in the community, we can prevent a hospital admission.  Hospital admissions are expensive, and for the group of patients I now work for, usually detrimental too.

Except that when you’re in a hospital you have everything.  You have a lab at your disposal, imaging, on-the-spot specialist opinions if urgently required, you’re surrounded by experts.  Out in the community it’s me.  Me and my stethoscope and doctors bag that has antibiotics, diuretics, and a script pad.  If I’m lucky a nurse will come out with me – the nurses I work with are for more experienced than I, they’ve been doing this gig for decades and before that, working in intensive care or emergency.

When I see my patients, I have to ask myself, what is the best for them?  Is it a hospital admission?  Is it prevention of a hospital admission?  Is that safe?  If I don’t send them to hospital, will they survive their ailment?  If I do send them to hospital, was it the wrong call?  Have I created illness for them, have I wasted thousands of dollars?

Last week I saw an elderly woman* who was delirious.  She’d had some blood tests a couple of weeks back which were helpful for me, but had been well in between.  Delirium is a hard one because my patient can’t tell me what’s wrong.  My patient didn’t have any pain (that much you can more-or-less elicit) and she had a catheter for her urine, the contents of which at a glance, was clear.  I gave her some juice and she vomited it immediately.  I examined her in a limted way – she couldn’t follow a single command and I couldn’t find any signs of infection or much else for that matter.  No medication change.  For all I knew it could be a non-medical reason, sometimes simply a change in staff, a change in bedroom, can cause a delirium in our older patients.  She was dehydrated.  The nurse offered to hang some fluids and I agreed and asked her to collect some bloods and sat down to write my notes.  I wasn’t keen to send her to hospital, surely I could figure this out, institute treatment, and keep her out of hospital.  But something was bugging me.  It was her colour.  People can take on a different tinge depending on what is wrong with them.  There is the yellow of jaundice, the flushed of infection, the mottled of sepsis, the pale of anaemia.  The greyish-yellow of uraemia (from kidney failure).

A million years ago I did a term as a renal (kidney) registrar.  It was easily the hardest term of my life, the level of responsibility given to me, given my junior level.  I wont go into details here.  But while it broke me, it made me, it taught me about guts.  My consultant at the time was a kind genius.  He would walk through the emergency department, and collect patients.  They would be admitted under other services but because he’d worked there for twenty years, he knew the whole community and wanted to look after them.  The other registrars would joke about never letting him go to the emergency department or you’d have the biggest round list in the world!

My genius boss, who knew everything and who loved people, used his gut a lot.  When faced with a problem he didn’t know the answer to, he would stand there for what seemed like an age, hand on his chin, and then eventually say “I think we should try this…” He never got it wrong.  It was wonderful to watch the 40 odd years of experience he had at work.  He never really articulated why he chose that and I’m not sure he could, it was just the weight of that experience influencing his gut.  I’ve always found this hard.  Especially in the exams.  There’s so much noise in your mind as you go through.  If you choose this, what about that?  What would others choose?  If you get it wrong does it prove you are as stupid as you suspect you are?  If you fail, what does it mean?  Does it mean you’re a terrible doctor, does it mean everyone will look down on you?  Isn’t that the right answer as well?  The answer is lost somewhere in all of that.

When the patient is in front of you, it’s even harder.  It’s none one of 5 options anymore, it’s 50.  My patient could have had a stroke.  She was delirious, she couldn’t swallow properly.  If I didn’t send her to hospital, was I missing a stroke?  I didn’t think it was a stroke, but it could be.  How would I know?  I sat there staring at my notes for a really long time.  I had no blood tests.  I had my examination findings, my history.  I had that strange colour.

The nurse returned.  I took a deep breath.
“I’m sending her to hospital.”
The nurse blinked in surprise, a little bemused.
“I think she’s uraemic” I blurt out, “I’m not a hundred percent sure, but if we send the bloods and wait for the results, and I’m right, she’s not getting into the hospital until 9pm and no one senior is going to see her for a while.”
“Your choice doc”.  It may seem a benign statement, but my wonderful, experienced nurse who knows far more than me, isn’t arguing.  And if they’re not arguing, you’re probably right.  But still, if I’m wrong, then I’ve put a lady through a lot of unnecessary and painful intervention, and cost thousands of dollars to a very stretched system.  There are so many points at which I could second guess myself.  So many wrong calls.  This could be a completely wrong call.  It would be so easy to talk myself out of it, go with inertia.

We organise an ambulance.  I ring the emergency department consultant.  They are never pleased to hear from me but we keep it polite because we both get it.  The nurse and I run the bloods back to the hospital ahead of the ambulance to expedite the patient through the department.  I call the patient’s next of kin and explain, they are accepting.  And then I move onto another patient and try to put it out of my mind.

Later in the day when I’ve returned to the office, the nurse claps a hand of my shoulder.
“Nice call doc – good to see you trusted your gut”.  She thrusts a printout of the blood test and brain CT in my hand and there it is.  Severe kidney failure, no (obvious) stroke, right call made, correct treatment and admission commenced on arrival.

When I was more junior, the glory would have been in making the right diagnosis.  There is no glory in this for me now, because it’s a horrible situation for the patient.  I’m glad that things were done correctly, but the glory is in the trust I afforded my own judgment.  It’s easy to make decisions when you have a lot of information available.  Out here, in the far reaches of the medical galaxy, it’s so different, you have so little at your disposal.  So my post tonight is a little bit of a pat on the back for me because you don’t often feel successful in this gig so that when you do, you’ve got to take a moment to enjoy it.

But as always, I have a point to make.  Exam sitters, when you take that exam on Monday, trust your gut.  When you have that moment when you think “I think it’s this but I’m not sure why”, no matter how faint that moment is, and no matter how much your mind tries to convince you it could be the other 4 options for so many other reasons (especially if you have an arts degree), hold that moment.  Trust your gut.  I get that you’re junior, that that muscle is as yet underdeveloped but it’s in there.  Your answer is in there.  The exams are the beginning of you finding your voice as a physician.  Don’t worry about failing.  This is the safest place to fail.  You wont harm anyone.  You wont have to tell anyone their loved one is dying.  You wont have to say to a patient “I made a mistake…”.  Your pride might get wounded if you do, but I don’t need to tell you that is nothing in the face of a medical error.

When you have that moment when your mind freezes, when you panic, when something screams at you “I don’t know!”, you know what?  It’s okay that you don’t know.  Half the time you really don’t.  Answer C, put a star next to it, move on and calm back to it later.  Or take a time out – stop, close your eyes, take 5 really deep breaths in and out, open your eyes, and keep moving, come back to it later.  The answer might come to you in a little while and if it does, wonderful, if it doesn’t, keep your answer at C.

You can’t harm anyone taking this test.  Your family is safe and unharmed, the people you love are okay.  You are okay.  This is all that matters.  This test is not who you are.  It’s a hurdle, sometimes you clear them, sometimes you crash into them and if you crash, you set it back up and you try again.  And the best part is that this is not a patient.  Even if you’re wrong, you’re not wrong, because you can’t hurt anyone doing this test.  On Monday, start trusting your gut.  It’s an ill-defined thing and it’s scary but ultimately, it’s worth it.

Good luck to all the candidates sitting the FRACP Part 1 Written Exam on Monday!

*patient information heavily de-identified and changed for this piece.

One last time.

I told a man he was dying today.  He wasn’t old.  His life had been written for him by his parents and his circumstances, and as we sat there, in his room, in a nursing home, even though he was too young and too cognitively intact for a nursing home, I watched the sun filtering in the window and I wondered why.

How did I come to be sitting here, and him there?  How had I been born to two parents who in spite of their mistakes, didn’t put me in danger, kept me safe, and warm and fed?  How had he been born into the opposite?  What had happened to his parents?

When I told him, he nodded, announced he was tired, then told me I should have worn more makeup to deliver news like that.  It was no surprise to him.  We both had a chuckle.  His writing had been on the wall for a while, and today, more than he was out of time, he was out of fight.  “No hospital” he told me, when I offered a last-ditch attempt to turn things around, “no more”.  I helped him into bed, he intermittently shouted at me, followed by intermittent sheepish silence.  We talked about palliative care, he signed the form with his wishes, not for transfer to hospital, call his social worker when he died, he wanted a funeral in a big church.

I wanted to hear everything.  I wanted to hear all his stories.  Why his bedroom was decorated the way it was.  Who he’d been.  There was no time.  Earlier in the week when I’d met him, he didn’t know me, he shouted at me for the entire visit.  I tried everything I could to try and turn the ship around, but decades of hard living, multiple diseases all conspiring against us, won against my feeble attempts.  When I discussed him with my consultant, she gently suggested it was his time.  There’s always a part of me that wants to fight and she saw this, she let me try.  When I saw him again today it was on his face and in my heart.

I’ve never told a person they were dying before.  On a normal ward job, by the time they get to you, they’re unable to talk or they’re already gone and you’re having that discussion with devastated family.  Today was a long and private discussion, met by my patient with quiet acceptance, with courage, and with peace, in spite of his young age.  There was a both a stillness and a rawness in our words, he was not the sort you could mince words and I’m not the kind to try.

At the time I was focused on making sure he would be comfortable and not be taken into a hospital system that at his stage, would do more harm than good.  We planned a goodbye party.  The chaplain brought him fruit.  Afterwards the nurse and I got in the car and drove to our next appointment.  And it wasn’t for a long time later that the seriousness, the specialness, and the immense privilege of that discussion hit me.

I feel both sad for my patient and happy to know him if only briefly,  immensely humbled to be a part of his final journey, overawed at his bravery and courage in facing it the way he does.  This is why I did medicine.

Something happens to you in medical school.  You forget about why you did it in the first place, you forget you wanted to help people.  You get stunned by bright lights, start trying for the impressive specialties, ditch the touchy-feely stuff in case people don’t think you’re serious about the scientific side of medicine.  You use all the jargon, no lay terms, you pride yourself on it, you assume that those who prioritise caring over the science of it must be covering for their lack of knowledge.  And then if you come to your senses and return to those values, you wake up inside that dream.  When I was done chasing the bright lights and found Geriatric Medicine, I told one of my bosses from a different specialty what I had chosen.  He pursed his lips and shook his head.  ‘What a waste’ he retorted.  I looked him squarely in the eye and loudly disagreed.  I wanted my resident to hear how wrong he was.

When I left my patient today, I said I’d see him again next week.  “If I’m still alive!” he shouted with the sort of cheer that is half joking and half sad.  He is why I did medicine.  I am humbled and rewarded to be his doctor, even for just a few days of his life.

At the end of the day, our team went through our list of patients.  Someone announced he was now discharged from our service, he’d been referred onto our palliative care colleagues.

“He’s not discharged yet” I said out of nowhere.  It’s my first week in this job by the way.   “I can’t.  Not yet.  I need to see him one more time next week, I need to make sure he’s comfortable”.

There is silence.

“So do I” says one of my nursing colleagues.

“Me too” says another.

We keep him on our list so we can see him just once more, and try to help just one last time.

Heart of stone.

I read an article recently about a survey into bullying of doctors specialising in intensive care (ICU).  One third of those surveyed revealed bullying, probably the tip of the iceberg  That, however, is not what disturbed me the most.  What disturbed me the most was that when these results were presented to the college, some smug upstart stood up and said the results weren’t valid because they weren’t statistically significant.  Statistical significance means that if positive, it would be representative of an entire population relevant to what was being studied.  Except that when you’re measuring qualitative things, such as, people, not drug responses, statistical significance kind of doesn’t really matter – if even one person has been bullied, it’s not okay.  The fact that this didn’t even register with that person, is symptomatic of the strange cult medicine has become.

When you’re a medical student, you’re so excited.  You did medicine because you wanted to help people, because you wanted to be proud of what you do.  You can’t understand why people in the field seem a bit grumpy.  Sometimes your consultant teachers are really mean, sometimes they make you cry or feel stupid, sometimes they make your colleagues all laugh at you because they’re frightened too.  And it’s normal.  It’s all normal.  It’s hundreds of years of history and nobility normal.  But it’s okay because medical school is still kind of a cocoon where you have your friends and you go to the pub and you have a few and laugh at the mean consultant and feel better about it.  By final year, shit is getting real but it’s still mostly okay.  Some people are wigging out because they want to be neurosurgeons since forever and they’re worrying about their careers but most of us have held onto that idealism.

When you’re an intern it’s really really really hard.  You’re thrown into these giant hospitals with hundreds of people, and lists of jobs longer than the time given to do them.  When you complain that you don’t get to go home on time, you’re told to be more efficient.  When you ask for benchmarks or KPI’s so you can try to understand what is expected of you, there is nothing but silence.  You’re too afraid to complain that the working conditions are outside of your award, because you want a career.  If you’ve even read the award, because it’s never supplied to you when you get hired.  ‘Good’ interns power through all their jobs with a smile on their face and never complain.  ‘Bad’ interns complain, struggle to do all the jobs because they spend too long trying to care about their patients, suffer extreme anxiety to the point of paralysis and ultimately leave the hospital for greener pastures because they didn’t feel ‘good enough’.  Never mind they got the scores to get into medical school or got through medical school.  Bearing in mind these two examples are extremes, everyone falls between the two.

The ‘good’ registrar (the person who is on a training programme to become some kind of specialist) is direct, and ascerbic, and doesn’t take shit from anyone.  They frequently bark at interns who ring them to ask for advice, seem to know everything, see their patients with lightning efficiency and not too much caring (because that will get in the way of getting through their work), and their bosses think they are great because they handle the inpatients for them (bosses do clinics and have private patients too), the residents trying to get onto the specialty programme try to emulate them, and the interns are left in tears by them, but ultimately, if they stay, become them.

The consultants are a mixed breed but encourage the direct-speaking, highly knowledgeable and acerbic trainee who doesn’t display too much caring because they make their job easier.  Some consultants like to make sexist ‘jokes’ in front of their trainees (usually female) but always ‘just joking’, some don’t let gender get in the way and employ the time-honoured ritual of humiliation, generally at the bedside in front of the patient, some just outright tell you that you’re useless, and some will try and tell you that you’re terrible as a means of getting you to step up.  Ultimately every junior person at some point feels like they’re not up to the job over minor things (like forgetting to order a non-urgent test) or that they are personally responsible for the safety of their patients and no one else (not true, medicine is a system with multiple safety layers).

And when the most ‘successful’ role models, are the way they are, you become that way too.  I painfully remember at the end of residency, having a busy and stressful shift, and snapped about one of the patients.  I had reached the end of my rope, the end of constantly trying to perform, to clear my jobs, to be that good resident.  I can’t remember what I said, but it was something particularly insensitive and uncaring about a sick patient (fortunately to a nurse and not to their face).  The nurse in charge stopped in her tracks and said “hey, that’s not like you.  You used to be lovely and now you’ve changed”.  I was mortified.  I’d been so process driven, so goal oriented, so focussed on being like the registrars that I’d forgotten there were sick people around.

It had seeped into my personal life.  When your patients walk the line between life and death, when your actions can dictate the difference between that, your heart becomes hard.  Your tolerance for the banalities of everyday life drops and you become hard as a rock.  You see so much terrible shit on a day-to-day basis that it’s your normal.  You don’t even know it’s terrible anymore.  When you step out into the normal world again, you think people are too soft.  You pride yourself on saying things like ‘harden up’ and see it as a point of pride that nothing gets to you, you find schadenfreude in the soft hearted around you suffering because you’re not and there’s clearly something wrong with them and something right with you.

Except you are very wrong.  That heart of stone is made of layers upon layers of vicarious trauma, from the huge amounts of patients with horrible illnesses and stories you’re forced to churn through without ever even getting to say “I’m so sorry” to them, to the hardened hearts of all of your mentors saying things like “toughen up, it’s good for you”, or “you lot are soft, we saw twice as many patients in my day”.  It’s made of completely normalised bullying, of colleagues who lack the integrity to stick with you because their career is more important, because once you get there, once you’ve made it, you can go back to being you again.  But you can’t.  Once there, you have to keep yourself there.  And to keep yourself there, you have to be as hard as a stone.

Later when I was a more junior registrar, one of my patients pulled me aside and told me he couldn’t believe how badly we were bullied.  I asked him what on earth he was talking about, that my consultant was lovely.  The gentleman was agog with disbelief, pointed out how badly each one of us had been humiliated when he was teaching us by the bedside.  I laughed it off at the time and said ‘oh that’s just the way he teaches, we’re used to it’.  I hadn’t even felt humiliated by then.  Once upon a time I would have been in tears.

While I was in medical school I would sometimes go to drinks with my husbands corporate friends.  One of those friend’s Dad was a doctor, and I was musing aloud what I would become when I ‘grew up’, tossing around different ideas for specialities.  That guy at the time told me not to let what I chose harden me, because that was his Dad’s biggest regret.  I didn’t understand what he meant at the time.  I know now.  Doctors are unaware that they are bullied by their colleagues, and traumatised by the double whammy of seeing horrible things happen to people, and not having the time to properly care for them.  In other health areas, like psychology and social work, there are weekly or fortnightly supervision sessions where the trainee can debrief and reflect and work out how they can be better.  This concept is met with suspicion in the medical profession, everyone is always so afraid for their career, they don’t want to be seen as soft, they don’t want to admit mistakes.

I’ve had a few opportunities for ‘greatness’ over the years. Offers to train in lucrative specialties, take on prestigious research and I was so tempted.  But I could see the writing on the wall by the end of residency.  I was becoming what I never wanted to be, that doctor that didn’t care.  You are presented with a clear choice at some stage in medicine, and that’s to go with or against your values.  Maybe it’s not so clear for everyone.   So I took the less prestigious road, I prioritised time and my family over it.  It stings sometimes, a comment here, some dismissiveness there, but I don’t care anymore.  As a medical student, older male doctors used to tell me to do general practice because it was ‘good for women’ (i.e. it’s not as time-intensive as surgery and critical care) but really, they all should be.

Only certain specialties are like this.  Some are lovely.  All have elements while some are overt, and there is no secret which, it’s been in the media enough.  It’s going to take decades to change and that’s being generous.  There is too much bedrock in there, too much fossilised, entrenched attitude, too many hearts of stone running closed systems, believing any opinion that there is something wrong with what’s happening is simply political-correctness gone mad.  They will joke about it to their registrars, say things like “you don’t think like that do you?  You’re one of the good ones!”, and “oooh am I bullying you right now?” and the registrars and residents and interns will laugh because they have no other choice, they will internalise these messages as correct.  And they need these consultants because without their expertise, people will die that they could help save.  It’s a very complex, powerful, codependent relationship, further reinforced by the medical workforce units, responsible for rostering and employment, who behave as though 80-100 weeks are normal and that doctors are lazy or ungrateful if they suggest otherwise.  Of course, on paper, no one does 80-100 weeks.

This post doesn’t really even begin to pick apart what is happening, and what has been happening under the public’s noses for a very long time.  It’s a tragedy.  Everyone wants the caring doctor, but they rarely survive through residency these days.  It’s cooler to be a tough and hard-nosed sort that isn’t fazed by anything.  Everyone is much more comfortable with that, except of course, our patients.  And our families.  And our friends.  All the people who really matter.

So to all my colleagues reading this, trust your instincts.  If it doesn’t feel right then it’s not.  If you don’t feel like you, if you’re crying in the cupboard or telling a family member you think their problem is nothing, just know that you’re still in there and you’re not the one with the problem.  The system has the problem and it’s inflicting it on you.  What you choose to do with your values, is still up to you.