Work

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.

Mojo.

Last night after writing that, I sat there and read over the last near-10 years of posts.  What hit me was how obviously hard-working I was, and the other thing that hit me was the gaps, and all the things left unsaid.  Reader, deep down I always thought I was useless.  My self-esteem has been so poor going through all of this, that I truly thought of myself as borderline-remedial.  And while it’s done a lot of growing up (because what else is low self-esteem really, than a small frightened child?), looking back over my posts broke my heart a little.  The enthusiasm, the genuine concern for her patients.  I always wanted to be that ‘star’ resident, that ‘star’ registrar.  And my career choice (not that I have regrets), has been very shaped by that poor self esteem.  I truly believed I would have no hope in certain specialties, and now I realise I would have been great in them, and would have been welcomed, if only I’d posessed a little more self-belief.  What makes you get hired?  Caring about your patients.  Being personable.  Not bringing your personal shit to work.  Clicking with the right team.  Not being so wound up and twisted-in-yourself-anxious that you can barely form sentences because when you’re like that, people can’t get to know you.

And then there’s the gaps.  2013, where the workload, the bullying, a miscarriage, and all the stuff that has made its way into the news now was my reality, where I truly fell apart.  2014, where I failed the written but had a baby which put everything in perspective.  2015 where I passed the written and the clinical with a tiny baby, but still so broken from 2013 I didn’t think any training program would take me because there was something inherently wrong with me.  I did no pre-interviews, no meet and greats and there but for the grace of whatever deity there is, I was offered a job in geriatric medicine.  2016, where I moved interstate with a baby, got no time off work and suddenly found myself in a new state with new systems, and a constantly daycare-sick kid broke me in a new way.  2017, another miscarriage.  2018, another baby, maternity leave.  And here we are now, 2019, two kids, full time work. So. much. change.

My new job feels like I’ve been hit over the head repeatedly like a hammer.  I am stunned.  Stunned by the flow of information coming at me, the meetings, the workload.  Slowly I find myself coming to, but at the same time slipping into that I’m-not-good-enough mentality.  It’s always hard when you start a new term.  You have to forge new relationships while remembering that everyone there has just lost a relationship with the last doctor, who mostly, they’ve grown to appreciate.  You can’t possibly fill their shoes.  They talk about your predecessory fondly while looking at you suspiciously, and by the time you’ve earned their trust and their love, it’s time to move on, only to do it all again.  And every little slip that I make, I feel like a knife.  Coupled with the fatigue that two small non-sleeping children bring, I find myself thinking ‘how can I possibly measure up?’.

When it comes to having a good short term memory and an excellent recall of exam-level knowledge, I don’t think I can.  I can be just good enough I think.  But I make up for it in other ways.  I make myself freely available to my patients and their families.  I tell them I don’t have the answer and that we can find it together.  I hold hands with unconscious patients.  I sit with crying adult children.  I’m painfully honest about what I haven’t done or don’t know to my boss because it’s the fastest way to trust when you can’t be that star.  But oh to be a star!  Oh to have that endless mojo of my resident youth that lent me the energy to walk 13km a night and do endless cannulas and want to change the world of medicine.  I hope it comes back soon.  I feel the weight of the years, of the impossible juggernaut that is the public hospital system in which it’s so difficult to enact change in the face of that endless historical resistance.  And the older and more established the hospital, the harder it is.  But I still hope.  I hope for a bit more sleep, for the motivation to exercise, to read studies, to be better.  I hope for my mojo back.  Hey two posts in two days – something has definitely changed, and I think for the better.

I am so tired.

Well it’s not quite a year since I last posted so I must be winning at something right!  This blog has been running since 2010 – I can’t believe it!  Pity it’s not more frequent but eh, you can only do what you can do.  So, 2010 was final year of medical school, 2019 is second last year of advanced training.  Can you believe it?  I know, I probably should be done by now but there’s two babies and two mat leaves and some part time training in there, so I’m not doing too badly.

When I look back over the last 9 years, it’s like looking over a series of mountains.  I can’t see the starting line anymore.  I’m not the same person by any stretch.  I’m harder in some places, softer in others, I’m pretty sure I’m much stupider than I was but I make up for it with lots and lots (and lots) of hospital experience.  And I’m also pretty tired of hospitals.  Some people never get over the merry-go-round and just love the acuity, the intensity, the perpetual high-functioning anxiety of it all.

But oh, I am so tired.  I haven’t slept since 2014 when my first was born.  I churn through patients and patients and patients and never quite get enough time with them because I’m drowning in paperwork and meetings and projects.  Every single little thought I have, every email I get, every meeting request gets scheduled, reminder-added, double reminder, or added to a task list with another reminder.  I get home from work and jump straight into my beautiful, relentless, children.  The evening routine of play-feed-bath-put to bed gets me to 9pm.  We wrangle dinner.  No time to make lunch if I want to sleep.  And my nights are filled with rocking my non-sleeping baby and breaking all the sleep-rules.  And then back to work, with it’s dizzying array of people, requests, and frightened, vulnerable patients and families.  I never, ever, thought it would be like this.  I had no idea.  It is just push-push-push all the time.

But less than two years to go now.  You sort of think after exams it will quieten down but it’s just a different kind of intense.  So many more competing demands.  And today I was sitting in meeting #92034783297892 and I started daydreaming about getting my letters.  Letters!!  FRACP!! I daydreamed about standing up at the lectern wearing a cap and a gown and shaking some dudes hand and getting a certificate, but really what it means is that I’m shaking that hand and walking through to my freedom from changing jobs every 3-4 months.  It will be ten years of a new job, every few months by that point.  When you think about it, it’s fucking ridiculous.  But that’s medicine.  So much of it is a level of ridiculous, delivered with full seriousness, gaslighting you into believing it’s normal.

So much is coming out into the media now, so much of my old normal which I never realised until later was overt bullying, sexual harassment, discrimination, abusive work hours.  I’m glad I’m out of all of that (mostly).  Junior doctor life, depending on where you land, is like Lord of the Flies.  It’s awful.  And maybe one day when I have my letters, I’ll have more perspective on it and maybe I can help.  But I’m so tired, I’m out of fights.  My former indignant, and usefully outraged self has been replaced by this pleasantly comatosed and somewhat zombie-like human who pastes on a smile and tells herself and everyone around her that it will be okay, that this too shall pass.  Less than two years to go.  My secret inner-catastrophising mind whispers “what if something bad happens and you never get to finish?!” Things that keep me up at night.  I have thrown myself at this wall over and over and over and the thought of that makes me feel ill.  But hey, they’re just thoughts, not realities.

I’m so tired.  And I can’t wait to be done.

Classroom anxiety.

I’m sure there’s a whole bunch of you studying for those infernal clinical exams, or know someone who is.  I do not look fondly on those days (few do, occasionally you get a misty-eyed consulting waxing lyrical about how they loved carrying their briefcase away), partly because they were, well, horrible and partly because I have classroom anxiety.  There.  I said it.  In public (of sorts).  I don’t know when it started and it was a very very long time before I realised it was a problem, but sometime between high school and med school, I became extremely afraid of classroom environments.  It probably got worse in medical school – there’s nothing quite like being an arts grad in postgrad medicine, busting your arse comprehending a chapter in your physiology textbook, fronting up to class the next day armed and proud with your newfound knowledge…and then getting absolutely owned by your cocky PhD wielding colleague who just happened to do their doctorate on that very subject.  And variations on that theme.  Daily and weekly, for a good two years.  Being the dumbest person in the room for a protracted length of time broke something in my brain and I didn’t realise it for a long time.

It started with avoiding lectures.  Especially the ones where the lecturer was known to pick on people.  The thought of being picked on, of not knowing the answer, of everyone discovering that I didn’t belong there, that I was in some way illegitimate was just too much.  Then suddenly when I began to study, learning new information became anxiety inducing.  I fell into this strange hopelessness that whatever I learned would never be enough, someone was always going to know more, be better, be more worthwhile, which in turn would reinforce that I was nothing.  So I began to avoid studying too.  Then my fears would be reinforced when I did front up to a class, and be berated for not doing the pre-reading, when all my other conscientious colleagues would dutifully know the answers.  The berating then deepened the anxiety and the avoidant behaviour got worse.  Eventually even when I did study, it got to the point in classroom situations that my memory became impaired by the anxiety of it all, and even if I had learned the right answer, it was gone.  Either it never went in from study anxiety, or it couldn’t come out due to classroom anxiety!

Occasionally I would have bursts of ultra-effectiveness, learn something really well, show up to class and know the answer…and then feel like an impostor because I’d learned it the night before and didn’t do it consistently.  Sometimes in your own mind there is no winning.

Clinical exam practice was particularly painful.  You have to show up, or you fail.  So I did.  I still remember being shouted at “DON’T FREEZE UP! YOU CAN’T FREEZE UP ON THE DAY!!” in front of everyone.  And while I showed up, I was still so impaired from the fear of it all.  I couldn’t pre-read because when I did, all I could think about was how I was never going to know enough or be good enough, or be like that awesome colleague who just studied consistently and practiced and did everything right.  I cried every day from that anxiety, and I was very very lucky that I had colleagues who stopped me in corridors and hugged me, or made me laugh to distract me.  Your colleagues are your everything in times like these.

These days I still freeze up.  I still hide in the back of the classroom hoping I wont get picked on.  In medicine people love being the one that knows the most, they love it when someone gets something wrong because we all love to show off our knowledge, it’s like a reflex.  But I still show up and don’t avoid, and sometimes the class is on a topic I know something about and even stick my hand up to answer.  It seems like such a small thing doesn’t it?  I take a lot of notes that I never seem to read, mainly to focus and calm down.  I look at my higher functioning colleagues, the consistent ones and these days I’m in awe.  I’d love to be that person asking the intelligent questions.  Maybe one day I will!

I look back over med school and my early career and wish I didn’t have this anxiety.  How amazing I would have been if I wasn’t so worried about everyone finding out.  Of letting go and allowing myself to be seen as stupid.  Of just letting go in general.  I’d get better marks, get along with consultants better – ah c’est la vie!  And the problem with anxiety is that it’s your normal – you don’t know you have it.  Your brain protects by coming up with perfectly reasonable excuses not to study, not to attend class, your ability to justify it is simply amazing, and you’re generally affronted if someone suggests anxiety to you because you’re so unaware of it.  Excuses are your reptilian brain’s way of protecting itself and it’s so hard to break free of them.  As the exam looms, try to notice it.  You don’t have to ‘fix’ it, just notice.  Through the practice of noticing, you find a new voice that takes you by the hand and leads you around the excuse, it allows you to put the anxiety into words with your colleagues, it allows you to start becoming that amazing persistent person.  And if you notice that it’s a really big problem – find a psychologist! It’s a really really really fixable problem and any performance coaching psychologist or educational psychologist will work with you and tailor a program to take it down from destructive anxiety to the best functional kind.  My very best friends have this amazing ability to take their fear and turn it into relentless study.  I’ve slowly developed the skill over time, and I’m very glad to be able to write this post because admitting it means it’s finally conquered.

Yesterday was Crazy Socks 4 Docs Day and this post was written in support of physician mental health.  We all suffer in this job and we are all in it together – I hope by admitting one of the things that has crippled me, that my readers can find a little solace.

On taking a break.

I am on maternity leave (again), with baby number 2 (she is beautiful and perfect and all good baby things). It occurred to me that this is the first time since starting medical school, that I’ve had a real break.  The first round of maternity leave was filled with exam study while learning how to be a mother.  You don’t realise how fraught you were as a new parent until you have a second!  Newborns are actually pretty easy, they sleep a lot and can’t run off on you, waving their pants in the air, bare bum disappearing from view.  I digress.  Holidays aren’t really a proper break, although to be fair, I’d had proper holidays denied since 2013 for a variety of classic medical workforce excuses, which one day I’d like to turn into a bingo game for all junior doctors to play, so pervasive they are.

And here I am now, with 8 glorious months off work.  It’s hard to put into words what a proper break from medicine feels like.  It’s like there was this giant piece of furniture in my mind that I didn’t know was there until it was gone, and suddenly there’s all this space in my mind.  All the things that were so hard to do before are suddenly easy.  Exercise?  No problem.  Healthy eating?  Too easy!  The other thing I realised is just how anxious we all are at work.  I’ve been reflecting on some of the advice I’d received over the years, which frankly, has often been terrible.  I remember in medical school, telling the gunner resident I wanted to do physician training.  She archly told me that I needed to start studying now (in 4th year med!) if I wanted to pass it.  Or this strange phenomenon of everyone putting their basic needs, like using the toilet, eating, or forcing down tears, enjoying their partners and friends, absolutely last for very little yield.  I’ve never been an angel in this game, but I’ve fallen into that trap time and again.  It’s so consuming.

Taking a break is like stepping into an open field without anyone there, but with all the knowledge and all the lessons you’ve learned so far, right there with you to examine.  It’s like getting to start again, knowing what you know now.  There’s so much pressure to stay on that conveyor belt, to never get off, that Something Really Bad will happen if you take time out to rearrange your head after so many years of grind.  You get a lot of bad advice from well meaning but out of touch people in this game.  A lot of that advice comes regarding parenting in medicine (given by people who’ve had the luxury of having a wife managing their entire home life), and taking time off (given by people who’ve never had time off and have developed maladaptive ways of dealing with things at work).  So many anxious people relaying their anxieties in the form of bad advice.  Things like “you can’t have a year off without doing something medical because people will think you did nothing”.  Like, you just sat there and stared at a wall for a year?  Like taking time to better yourself, or expand your horizons, or raising kids is nothing?  Sometimes becoming a better doctor has nothing to do with medicine, and everything to do with where you’re at in your heart and your mind.

I know the clinical exam is coming up.  I remember so well how I felt afterward.  I wasn’t brave enough to take a year off after that.  Even a few months would have been enough.  I used to be so scathing of people who quit before their contract finished, but I get it now.  It’s not great that it happens, but I so get it.  It’s a function of a system that pushes people to the edge, and walking away probably does pull those who do it back from the edge.  I wish there was enough redundancy in the system to allow trainees a proper break after the exam onslaught, not the token couple of weeks you’re graced with.  When you’re at the coalface of human suffering, combined with those exams, and all of the personal life you miss out on, compounded by all those previous coalface years, it changes you.  Taking a break, whatever the reason, is breathtaking in that once the job falls away, you’re met with the self you thought you lost all those years ago.  If you can, do it.  If you can’t, plan for it so that at least it’s on your horizon.

Oh, the places you’ll go!

I was looking through the archives of this blog (now added to the sidebar) and had to shake myself – wait, I’ve been a doctor for 7 years?  I’m PGY….7?!  When did that happen?  I feel like internship was yesterday, I feel like I was scurrying around the bowels of the hospital, the weight of responsibility for every patient ever weighing on me, and the anxiety that I had normalised crushing me like a vice.  Struggling to find something to write about, I had a look through some old posts and realised that I had so much free time before I had a child!  I thought back then I had no time…but goodness, knowing what I do now, I felt downright jealous of myself.  All those posts with food experiments, sewing, coherent musings on life.  Of course, my daughter is the absolute light of my life and I wouldn’t trade any of that for her, but how strange time as a concept is.  We never think we have time.  We have one child, no time, and then people go on and have 2, 3, 4 and laugh at their earlier selves.

Anyway, PGY7?! (Post-grad year 7 for the uninitiated).  On Facebook today I saw some colleagues had got through their surgical fellowship exams and I felt so proud.  It is such a long, long, long road.  From that first year of not knowing what the hell is going on and feeling stupid 120% of the time, to that year of overconfidence of residency, then back to feeling stupid 200% of the time, of being that person in the room where everyone is nodding at the lecturer and you’re pretty sure you’re the only one who doesn’t understand, to those effing exams, and then onto advanced training…and all of your own life in between and that’s not even close to putting it into words.

7 years ago I wrote a post about choosing life over prestige.  About your head is filled with noble ideas of curing cancer, and doing highly ranked research, of doing the super duper prestige specialty.  I mused if intelligent and smart people also did the less prestigious ones (they very much do).  And I said I felt like physicians were the guardians of humanity.  Virchow once said that “physicians are the attorneys for the poor” and in my 7 years I have learned often that he was right.  It’s not until you do physician training that you realise the power of advocacy, of advocating for your patient – and their family.  I can’t tell you how many consults I’ve had where someone’s discharge has been delayed because of ‘unreasonable family’.  But usually they’re people who, in terrible circumstances are afraid and not at all understanding of the behemoth they’ve been forced to engage with.  I’ve written countless medical reports in support of my patients to help them escape terrible situations, I’ve kept them in hospital for this.  And I’ve argued with so many teams about not sending people home, teams who are getting crazy pressure about ‘beds’ and ‘lengths of stay’ (the amount of time a person spends in hospital – the hospital only gets money for a certain amount of days and past that it’s out of their budget), where I’ve had to pull the card that reminds the other person on the other end of the phone that my focus is on what’s best for our patient.  The managerial overreach seems to get worse every day, and every day I daydream about how well we could do with endless money.

When I was more junior I used to think that the ‘serious’ medicine was in the knowledge.  In the research, in the molecules, in the jargon.  Maybe it is, I’m not sure.  For me the medicine now lies how to improve lives.  Not just treat diseases.  Anyone can memorise and spit out a treatment protocol.  It sounds really impressive when you do.  But learning how to step back and say, hang on, what’s going on here?  What’s happening in this persons life that is contributing to this?  This is the part of my job that I love.  It took me a while (and some horrendous exams) to stop reducing people to a list of jobs, to a list that I constantly wanted to shorten and start listening, and working out a way forward without having to spit out treatment plans.  Those plans are important of course, but with every human you encounter, there is a bigger picture.  At some point I had to relearn compassion.  Pain is real, even if someone else’s pain annoys you.  The elderly are part of who we are, they deserve all of our respect, all people do.  Compassion for stressed out and anxious families needs to be endless, we need not be combative.  And compassion, not empathy is ultimately what gets you through.

PGY7.  Not even including medical school.  Years and years of facts and physiology, of problem solving. And for junior me, and junior you – yes it’s worth it.  I never knew the power of this job until I got (for me) what it is really about.  It’s sticking up for your patients, it’s wanting better for them and their lives, it’s asking them and yourself how you can achieve it.  It’s demonstrating patience, compassion and endless validation and reassurance.  Your knowledge keeps up on it’s own after a while.  But the other stuff is an endless and wonderful practice.

You have to find the bright side.

We’ve had a lot of media coverage about how hard being a junior doctor is now.  It’s barely the tip of the iceberg but it’s given me a lot of pause, and now that I’m part time, working a subacute job in an acute hospital, I actually have more time to listen to what’s happening around me.  It’s not pretty.  I overhead an intern replying “or, I could put a knife through my heart” when told she needed to do a discharge letter right now because the ambulance was there.  No one had warned her.  Discharge summaries take a while to write and she was mid-ward round.  I saw another guy slamming the desk repeatedly because hospital computer systems.  When I went to see a consult I noticed the intern was pale and shaking and when I told her gently that she was doing a good job, she collapsed into tears.  Her registrars were being arseholes, because their bosses were being arseholes, and she didn’t play the ‘flirt with your registrar’ game.

And for a while there I felt pretty down.  All that media coverage, all that I was witnessing, not to mention my beautifully suppressed own horror stories, and reader, I could write a trilogy and come back for two prequels with all the terrible stories I have, it was so much.  The media would love my stories.  And they’re never going to get them.  The media coverage has given me this strange sense of contagion and in a way, it’s made things worse.  This had to happen, it had to blow up, and it was always going to but the more I read the more it brings up for me and I was lucky enough to make it through junior doctor life in spite of my horror stories.  I maladaptively coped in my own ways, I stepped back from the glory of the acute limelight in the grey area of a subacute world that isn’t glamorous, that doesn’t aim for cure of anything but focuses on quality of life, sometimes at the expense of length of life. I found the people who think and feel like I do and I joined them.  And when I’ve done my training, I’m not interested in a system that eats it’s young.  I’ll stay in it to some degree because you always need the peer review of a public hospital, but that once noble cause of contributing to free healthcare for all in a collegiate system of respect (not to mention residents quarters and feeding the staff) is gone, fallen victim to an intensely cynical political environment focused on numbers that can’t be perceived to be giving ‘handouts’.  The result is everyone measuring themselves by numbers, how can we reduce the numbers, how can we turn them over, how much can we do in the community that we don’t have to do in hospital (hint: nowhere near as much as you’d think).

However.  I did not make it through this far by focusing on all the failings of this system.  Your life is very much dictated by the lens through which you view it and you can throw on the green glasses or you can throw on the rose glasses.  Choose the green glasses and everything looks sick and rotten.  Choose the rose glasses and everything is warm again.  The greatest thing that medicine has ever given me is collegiate relationships, of genuinely liking who I work with, and you can see this everywhere.  They’re tiny little moments that get drowned by all the traumatic stories, self doubt, horrible days, days where you don’t eat or pee but they’re there.  It’s the nurse who hands you a cup of tea and a biscuit, or put in that catheter for you because you’d done a grand total of one but back in Hong Kong they were the catheter nurse but aren’t allowed to do them here because paperwork, it’s the colleague who listened in the corridor to your bad day even though they had so much work to do themselves but don’t mind because they get it.

It’s the consultant who buys you a coffee and takes you to lunch even though you can’t figure out why because you never feel like you’re up to scratch (hint: expectations are lower than you think), it’s the guy down in rostering who sympathetically listens to your rant about the unsafe roster and actually changes it, it’s the person you’ve never met who asks if you’re okay then hides you in an unused office so you can cry it out.  There are people who care everywhere.  You can’t see them because you’re so afraid, so wound up, so withdrawn and scared that someone might find out how you’re feeling.  You feel like you’re alone in this world of overperforming heartless extroverts who loudly tell you that they have no idea what you’re talking about when you complain about how hard things are (hint: that’s their way of hiding it).  And yet, here you are back at work, tired beyond belief and unable to remember when you last washed your hair, and there again is the tea and the biscuit, the registrar who buys you a coffee, the nice lady on the switchboard who asks how you’re going.  We are all here.  We are all here for you.  We might not be visible immediately – but that person who stays to listen, who gives you the biscuit, who hides you in the office, those are your people.  Get their number, find them again.  Find the rotation where you got along with everyone the best and consider that as a career.  I was presented with a very clear choice of pursuing a field where I could not be more different in personality to the people I’d be with, vs the one where I loved everyone.  I chose the latter and haven’t looked back.  Don’t be afraid of finding your people even if the path is different to the one you envisaged for yourself.  Our values and ego don’t always line up, but if you can put your values above your ego and live close to them, you will be happy.

I can’t fix the culture.  I’m sure as shit not going to tell you to ‘build your resilience’ because that’s bullshit – you are not the problem here.  Find your people, get home from work and get on the couch with a block of chocolate and some binge TV.  Buy an expensive handbag after your run of nights.  Go on holiday to Europe and eat some food, lie on a beach in a tropical place and do nothing.  Find the things that make you go “aaahhhhh” with happiness.  Learn to shake it all off a little bit because you’re really not the problem, and you’re okay.  Learn to laugh at it a little bit.  Because slowly but surely it does get better as you gain knowledge and experience and autonomy.

And if suddenly you find that all the things that used to make you go ‘ahhhh’ simply don’t anymore, if you find yourself wondering who you are because you don’t like your favourite food anymore and can’t get excited about going on holiday anywhere, this is what you need to do.  You need to buy private health insurance.  You need to find a psychologist practice as physically close to you as you can find.  You need to ring them up and tell them you need to see someone.  You don’t need a GP referral, you can just pay privately if you’re more comfortable with that.  When you go to that appointment, all you need to so is sit down in that room, and say “I don’t want to feel like this anymore”.  Your psychologist will take it from there and you just need to let it all out.  You need to buy your psychologist chocolates at the end of it all because the person you will be when you leave that room will be greater than the one you have ever known.  I know you shouldn’t have to, I know none of this is your fault and why should you have to put yourself through this when other people made you feel like this?  The answer is, because you don’t want to feel like this anymore.

Find your bright side.  It’s in the dark humour, the biscuits, the strangers who listen and the colleagues who care and the psychologists who are visibly horrified by your stories and want to help you feel better, who tell you that you’re fine and the system is royally f***ed.  It’s in your family who welcome you home where you’re warm and safe and fed, and the friends who laugh and cry with you.  Keep showing up each day and doing what you do.  We all appreciate you, we know you’re doing the really high volume stuff.  Keep trying to find the bright side, no matter how small, let the cracks of light in.  Try to sleep as much as you can.  Learn to say “f**k it I’m having lunch” even if the other juniors look at you funny and watch how the sky doesn’t fall and the sun keeps on rising.

Ten things everyone should know about geriatric medicine.

  1.  High level care does not mean bed bound and demented beyond humanity.  Often it can mean doubly incontinent but completely with it and social and happy.  If you receive a patient “from HLCNH” this is not license to immediately turf them back because you’ve made the above assumption.  You must ask why they are in this level of care before you decide.
  2. If you can’t quite tell if someone is delirious, before you do that B12/folate/TSH arrangement, try  download and print out a CAM or a 4AT.  Both are four short questions which will help you.
  3. Nursing homes aren’t called nursing homes anymore.  They’re called “Aged Care Facilities”.  Why?  because it’s misleading to call a facility a nursing home when there’s no nurses.  There’s ‘carers’.  And maybe one RN to give out the medications.  Nursing homes are not like mini hospitals.  There is no inprest.  There is no bladder scanner.  Sending people back there with drains and medications that need dual signatures will score them a trip back to hospital.
  4. You don’t have to get the not-for-CPR form signed on the first phone call but it’s good to ask anyway because advanced care planning is a process and family members need time to think it through and have lots of discussions.  Initiate the discussion.
  5. Elderly patients can have acute abdomens too.  They might not be able to tell you where the pain is but it is up to you to think of it and if you suspect it and can’t rule it out with the history, rule it out with the CT scanner.  Non-con will still show a mass.
  6. Pneumonia and antibiotics WILL send the INR sky high.
  7. Listen to the family.  Listen to the family.  Listen to the family.
  8. If a nursing home can’t give the palliative medications overnight, and you don’t want to get the on-call pharmacist in to dispense them, don’t discharge them.  Not only is it obviously cruel, but it’s also illegal to deny a patient palliative care and it could be career-ending for you.
  9. An inappropriate investigation in this cohort is one that will cause harm.  Most of them don’t.  And while it may not change your management, the family sure do like to know what has caused their dearly loved mother to start to die.  It’s called closure.  Obviously don’t do a PET scan but it’s okay to investigate even when it seems futile.  Never use the word futile out loud.
  10. Listen to the family.  Even if they seem unreasonable and ‘demanding’.  There is no greater power than love.  It drives people to madness.  Listen to them, try to accommodate them, take a deep breath and be patient.  And when they say “something is wrong”, find that something because 99% of the time they’re right.

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.