Sunday, 8 March 2015

It's not 'lady doctor', it's doctor


The Age published an article this week that has made the medical community livid. Dr Gabrielle McMullin, a Sydney vascular surgeon, is being berated for the following statement
"Sexism is so rife amongst surgeons in Australia that young women in the field should probably just accept unwanted advances"  

Her comments relate to a female surgical trainee ‘Caroline’, who reported her senior for sexual harassment, and has since been unable to find work in a public hospital. 

Let’s not kid ourselves that Caroline's story is an isolated case. We simply know about her case because she took the advice we all shouted at our computer screens when we read Dr McMullin’s comments. Unlike most sexual assault victims, Caroline was empowered to make a report, even though it meant reporting someone directly senior to her. Caroline did exactly what we hope our sisters and daughters would do should (God forbid) they find themselves in this situation. However in an awful, but not that surprising twist, reporting her sexual assault cost Caroline her career.

Now lets consider the hundreds of other cases. The ones who didn’t make the news. The ones who, excuse my vulgarity, ‘got on their knees’, because it was easier. The ones who were too scared to tell anyone their boss made a pass at them. Or the ones who did confide in another doctor only to be told ‘keep your mouth shut and you’ll be fine’.

Keep your mouth shut and you’ll be fine. Medicine’s secret catchphrase.

Dr McMullin is not the problem here. She is simply the messenger. The problem here is a system where reporting sexual harassment is vehemently discouraged. A system where a young doctor successfully takes her assailant to court and is never employed by that system again. A system where big names have stood up this week and said sexual harassment is not a problem in medicine.

A quick glance at the female doctors I follow on twitter would disagree. We all have stories about sexual harassment at work- some of them subtle, some of them shocking. And yet person after person (mostly men, although I can't imagine why), have stood up and said sexual harassment is not a problem in medicine.

Perhaps we aren’t understanding what sexual harassment is. Perhaps we’re associating it with only the extreme example of rape, when it encompasses so much more than unwanted physical touching. Sexual harassment is ANY harassment in the workplace, involving unwanted sexual advances or obscene remarks. In its most subtle form, sexual harassment is every time you make a comment to a woman, whether in jest or sincerity, that you would not make to a man.*

Hence sexual harassment is every time you call me ‘blondie’ or ‘barbie’, every time you make a joke about my choice to wear a skirt not pants, every time you comment on my appearance rather than my skillset, every time you call me a ‘lady doctor’ instead of a ‘doctor’.

Sexual harassment is 2 weeks ago when I lead a code blue which saved a woman on the labour ward & my male colleague arrived after the fact & said ‘they shouldn’t send you up here, you’re too clucky’.  
It’s the consultant who commented that I’d ‘obviously gotten to where I was at a young age because I was pretty’ (Um, maybe I’m actually good at my job?) 
It’s the surgical registrar who told me if I wanted to be taken seriously I needed to dye my hair dark. 
It’s that I’m a little bit scared I’ll lose my job for writing this blog post.

‘Oh but that’s banter!’, you say. ‘Learn to take a joke!’ ‘Don’t be so lame’.


Have you considered the extent of what we hide under that lighthearted term of ‘banter’? This banter is what has allowed the subtle undercurrent of sexual harassment to become a well accepted part of our profession. The fact is, these comments are so common and unexciting that we forget that they are not okay.
These seemingly harmless comments, coupled with the line that we 'need to take a joke', teach women in medicine that they need to just accept everyday sexual harassment. And worse still, they encourage those deeds further along the spectrum of sexual harassment.

Where do we draw the line between commenting on someone's appearance to commenting on her body to making an unwanted sexual advance? Clearly we're having a great deal of trouble with the grey zone, so why don't we stop subtle sexual harassment where it starts. 

Now I’d love to be such an influential blog that I could ask hospitals and colleges to make clear their processes for reporting sexual harassment, or for a public campaign to stop #subtlesexualharassment. But I suspect my blog's reach is about 5 people including my mum.

Instead I’m going to ask you, that this week you look out for subtle sexual harassment and call it out. Whether you’re the med student, the consultant, the nurse, the dietician or the plaster tech, that when you hear a comment towards a woman that would not be made if she was a man say ‘hey! Let’s not make jokes based on gender’, or 'i don't think that's appropriate'. 

Maybe, just maybe, the tiny ripples of change could start here. 


*I am very aware that sexual harassment also happens towards men, however I don't feel I'm in position to comment on that. Nonetheless, let’s not dismiss this problem just because it applies to both genders. If you have a story on sexual harassment as a male in a hospital and how your female colleagues could empower you, please let me know & I’ll publish it on my blog.

I'd like to acknowledge and thank the amazing people I follow on twitter who helped me form the ideas in this blog. Most notably: @trisha_the_doc @dr_fiona @allan_katie @michelle_li @tweediatrics & @_thezol 

I have been lucky enough to work at many hospitals during my training & through locuming. These views do not represent any of them, nor the college with which I have a training position. The hospital I am currently employed with is incredible and supportive, but as this blog approaches 1K shares on Twitter and over 10K views it's clear this problem is not hospital-specific, it's medicine wide. 

Saturday, 24 January 2015

A letter to my patient with cancer

Dear patient, 

I hope this letter finds you well. 

It seems foolish to ask if you remember me. I'm sure you couldn't forget me if you tried. I'm the centrepiece of the worst memory of your life. I was the doctor who broke the news you were dreading, that you had cancer. Stage 4 cancer, incurable cancer. 

I'm sure you'd recognise me if you saw me in a crowded room. My face was the last thing you saw before you lost hope. My face destroyed your world. 

When you're a doctor, telling a patient they are dying gets easier. It does. In fact, with time some doctors seem to forget that even though this is the hundredth or the thousandth cancer for them, it's their patients first cancer. You didn't know this then, but your cancer was my first cancer as well. Since that conversation I've diagnosed many more cancers, and I've told many more patients they are dying, but your story has stayed with me. Your story, I'm sure, will stay with me for the rest of my life.

I first met you in a busy emergency department. You'd come in with a cough. (Just a cough!) But something wasn't quite right. I had an uncomfortable feeling from the moment I met you. Two years later I've learnt that that feeling- that sinking, nauseating feeling in the pit of my stomach that a patient is much sicker than they look- rarely lets me down. You taught me that. 

Your X-ray showed pneumonia and I admitted you, but after two days of antibiotics  you weren't getting better. Then the lab called and said your pneumonia was caused by a odd bug. A bug sick people get. But you weren't a sick person. You were 37 and fit. Why did you have this bug? I came back and asked you the same questions I'd asked you in the ED again, but this time you told me different answers. You told me about the weight loss, the sweating at night, the blood when you coughed. 

The next day we scanned your whole body, but really we already knew what the answer was. There was cancer everywhere. We think it started in your lung but it was now in your liver, your bones and your brain. Inoperable. Incurable. You probably only had weeks left. 

I remember breaking the news to you like it was yesterday. We were both terrified but I was pretending I wasn't. I told you that I was sorry, and I truly was. I hope my voice didn't shake. I hope my face was kind. You cried and my heart broke for you. I wanted to hug you and tell you things would be alright. But I couldn't, and they weren't going to be. I hope you didn't realise that when I left your room an hour later I was crying too. 

I took your cancer so personally. I felt that I had failed you by not being able to offer a cure. I cried myself to sleep for many, many nights and tormented myself that if I'd seen the signs the second I met you, or that if I'd taken a better history you could have been saved. I know now there is nothing anyone could have done. 

You accepted you were dying long before I did. In fact, I didn't accept your death until long after you'd gone. You weren't the first patient of mine to die, but your death left me broken. I felt like I wasn't worthy to be a doctor. That I should have been able to save you. 

You were only with me for 4 short weeks, but in that time you taught me more than many of the professors and teachers I've known have taught me in years. You taught me to be empathetic but wise, compassionate but brave and that being vulnerable and emotional were both my best and worst qualities as a doctor and a human. You taught me that I couldn't save everyone, but that saving people wasn't always what mattered. There were more important things in life - dignity, kindness, being at peace with yourself... 

I knew back then that my face was the one that changed your world forever, of what a huge role my character played in the story of your life. You didn't know then, what a huge role you played in mine.

I hope this letter finds you well.
I hope you found the peace I couldn't give you.

Yours most sincerely,

Your doctor. 

Sunday, 4 January 2015

About to become a real doctor?

Here's a little list for the panic attack you'll have the night (or the week) before starting internship. Things you need to do to prepare for your first day as a real doctor:

1.   Find your 'system' 

Remember when you used to imagine that after graduation it would be all life saving & meaningful doctoring? I hope this isn’t the first time you’ve been told that’s not the case. The best quote I can use to summarise internship is this:

‘I’m okay at treating heart failure, but I’m excellent at sending faxes’ 

The best interns aren’t the most brilliant clinically, they are the most organised. Hopefully you spent a bit of time in final year med school observing junior doctors systems and have seen what works and what doesn’t. The same system doesn’t work for everyone, but these are the basics:
  • A paper-storing mechanism 
Option 1: Lots of people use 'nerd boxes' like this which have a handy clip to attach your patient list at the front, and can store various papers inside. The flat surface means you always have something to write on. You can prevent your papers inside getting mixed up by using paperclips to group like papers.

Option 2: I used a ring binder like this which I attached a bulldog clip to the front of to hold my patient list. I then had my various forms/papers in their own plastic sleeve which meant they never got mixed up and I could find them very easily. A bit bulkier than option 1, but more organised.

Option 3: Haphazardly collect various bit of paper you will need and clip them together using a bulldog clip. This system is the least bulky and you can easily access things, but if you require more than 3 different types of paper/forms, its probably not the best. It also has the advantage of being replaceable if you lose things easily.

Option 4: No system. This is not an option, unless you want your co-intern to hate you (I'm looking at you, surg co-intern)
  • Blank supplies for your paper-storing mechanism
Basic: Progress notes, medication charts, iv fluid charts, pathology/radiology forms, blood product forms

Med: echo/cardiac procedure forms, any special condition forms (my hospital has a flow chart for pneumonia, CCF, cellulitis), special ward round forms if they exist, consult sheets

Surg: consent forms (x a million), elective admission forms, patient information sheets on common procedures (taken from outpatient clinic)
  • A way to write down jobs
This seems obvious, but some people don't do this!! You WILL NOT remember things unless you write them down. Every little annoying job you get given you should write down. This job list can either be on your patient list or on a blank piece of paper.
Draw a little square next to each job so you can tick it off once you're finished.
  • Results (unless the iPads at your hospital work a lot faster than the ones at mine)
Our patient list printing system handily prints off blood results, however its almost never adequate for what your consultant will ask you.
If blood results are available before ward rounds, you should get to work early to write them down.
If not, do a 'blood result' paper ward round after the actual ward round. Don't not check results, not acceptable.
Depending on the rotation/consultant there are different specific results you will be expected to know (HbA1c, CMP, Vit D, serum rhubarb), you'll know after the first ward round.

For radiology results, if the patient has had a CT/MRI/fancy scan I found the best way was to print the report & have it in my paper storing mechanism to hand to the consultant.
  •   Lots and lots of pens


2.     Have a cheat sheet

You can borrow mine here, but I really recommend making your own.
I was really nervous about arriving at ward calls and not remembering what I needed to do for chest pain so mine has a lot of managing ward calls. At the very least write down doses for common drugs.
Even if you remember them all now, there's nothing worse than having to google 'dose of paracetamol' while your consultant breathes down your neck.

3.     Invest in comfortable, professional shoes

Girls, I can't recommend these shoes enough. Expensive but I wore them every single day of internship and residency. Thanks to my wonderful friend Nicola for introducing me.

4.   Invest in a satchel/place to put your doctoring things

My doctor bag looks like this and contains: wallet, phone, USB phone charger, so many pens, penlight, lip balm, muesli bar. It should contain a tendon hammer, but it doesn't (Sorry Prof Storey)
You could also use your pockets for this.

5.     Get a GP

I know you think you are so healthy that you don't need one but if you want to stay that healthy, get a GP. One you like. Go and see them early this year and get your OCP/ventolin script, that pap smear/STD check you've been putting off, and let them be proud of you for being a doctor. If you're super lucky you'll only need to see them once a year for this visit. If you're like most of us type A anxious types, you'll see them more often.
If you email the Victorian Doctors Health Program they will give you the names of GPs willing to treat doctors in your area.

6.   Accept you will feel very stupid, very often

Oh how I wish someone had told me this before internship started! I was a good med student and I thought that meant I would be a good intern. I don't think anyone actually feels like they are a good intern. You will feel like you know absolutely nothing most days, and the only reassurance I can give you is that everyone else feels the same way, they're just hiding it very well.

Internship is super overwhelming! It's totally normal to cry on the drive home (but not every night).
Make sure you have a good group of medical friends to debrief with & some non-medical ones to remember how to have real life conversations with.
Take up those hobbies you have neglected for all of medschool. Go for a run. Don't drink too much wine. Call your mum.

It will be okay. You'll survive. :)



Sunday, 6 April 2014

What happens when there is no one to advocate for a patient?



I was recently told a story about an elderly patient on a medical ward. She was frail, almost 100 years old and spoke no English. She presented with a relatively minor ailment, however, at some point in her hospital admission became severely unwell. Due to a multitude of factors, not in the least her language barrier, her diagnosis was delayed and eventually the decision was made for palliation. She died soon after.

I heard this story from the perspective of someone in allied health who was extremely upset by it. To my surprise, he didn't care when I said that this particular condition was always terminal and palliation was always the outcome. That wasn't the point, according to him. The point, was that because she was non English speaking and had no family around, she slipped through the cracks. The point, he said, was that nobody fought for her.

At first I didn't understand this. How could he honestly believe that no one had fought for her? Like all hospital patients, there were so many people involved in this case - interns, registrars, consultants, medical students, nurses, physiotherapists, occupational therapists, pharmacists, dietitians, social workers - how could no one have fought for her?

On further reflection, this comment really upset me most as a doctor. Isn't that why I'm a doctor? To give my patients the best possible outcomes? Isn't my role in the hospital to fight for my patients? What am I doing as their doctor then, if not fighting for them?

Maybe that is what differentiates a competent doctor from a great doctor. Every doctor knows what the standard treatment, or even the most evidence-based treatment, for pneumonia is. But that's not necessarily the best treatment for a particular patient. Being a brilliant doctor is about understanding the values and attributes of the patient as an individual and being sure that our management aligns with those individual qualities.

For most of our patients, this isn't a problem. The patient will tell us when something isn't right, they will advocate for themselves. For the most part, the patients are involved in the decision making and given the chance to question and even refuse the proposed treatment. Where they can't, as in the case of elderly or otherwise impaired patients, their family takes up this fight on their behalf.

This begs the question though, what if there isn't family to fight for them? Who advocates for our patients when they can't advocate for themselves? Who fights for our patients who, literally or figuratively, don't have a voice?

It's not that doctors aren't giving their patients the best care they can offer. In most cases they are. In most cases, what the doctors believe is the best treatment for the patient is what's right for them. However, in the minority of cases where it's not, we look for feedback from the patient or family to let us know so we can change.

So in that rare case- the 90yo from a nursing home with no family- who makes sure we're right? Who notices that in the week since admission her independence is slipping? Who notices that she's 'just a bit off'?

A patient who doesn't have family should ring alarm bells to us as health professionals. As should any patient who can't communicate due to a disability, a language barrier or their age. These need to be the patients we spend extra time with in ward rounds, and spend extra time thinking about. There is no safety net with them. There is no worried daughter to tell us 'dad isn't his normal self'. There's no one to catch our inevitable mistakes.

These are the patients where it is especially important to ask, if this were my grandad, what would I want done? Would I be happy with this explanation? Would I expect more?

These are also the patients where everyone on the team has the obligation to raise issues with the management plan. A colleague of mine told me of a patient he suspected had lung cancer but never raised it because he was the medical student and none of the doctors gave it a second thought. That patient represented months later with metastatic disease and that colleague has to live with always wondering if there would have been a different outcome if he'd fought for that patient.

These are the cases where a proactive medical student, nurse or allied health professional can make an enormous difference to a patients outcome. Fighting for someone who can't advocate for themselves might make no difference to their outcome, but it might change everything. We miss things as doctors, and we we make mistakes all the time. We need patient advocacy, whether from the patient, family or someone else on the team, to make sure things turn out okay.





Friday, 31 January 2014

General Medicine: Swapping Zebras For Horses

Doreen is an 81-year-old lady referred to general medicine by the emergency department. She doesn't have a black and white diagnosis like 'right lower lobe pneumonia'. Our patients rarely do. She does have a cough, and a history of chronic obstructive pulmonary disease, but her chest X-Ray is non-specific and the respiratory team don't feel she is unwell enough for non-invasive ventilation or admission under their team.
Likewise, the cardiology team were unexcited by a mild troponin rise but agree she has an element of heart failure.
She is certainly in renal failure, but nephrology weren't even consulted because it's clear a moderate creatinine rise isn't her main issue.

Doreen, like many general medicine patients, has a little bit of everything. A mild of an exacerbation of her COPD, a bit of heart failure, and acute on chronic renal failure. She has a touch of diabetes, hypertension & cholesterol, pretty severe osteoarthritis and is falling more in the past 6 months. She's definitely anxious about those falls, and about being a 'burden' on her family.

It's 9pm on a Saturday night when I see Doreen. She's in her dressing gown in a cubicle in the chaotic emergency department. She's with her husband Louie, who is a bit hard of hearing and walks with a limp since a stroke 4 years ago.

Unlike the agitated patients around her, Doreen is delighted to see a doctor. I take a history and examine her, and think about what she really needs from this admission.


What she needs is a doctor who is realistic about her conditions and what can be achieved, but also what is worth achieving. Modern medicine does mean it's possible for her to have perfect blood pressure control but if 120/80 means she gets dizzy when she stands too, it's not the number to aim for.
She needs a doctor who'll explain things to her, honestly. Yes, her breathing will get worse over time with the COPD, and each chest infection lowers her baseline function a little but further.
She's needs to know that if her heart was to stop beating, doing 'everything we could' would not be in her best interests. Being intubated and attached to lots of machines in the ICU would be unlikely to help, and would prolong the inevitable at much emotional expense to her family.
She needs is a doctor who understands that death isn't a consequence to be avoided at all costs. Death is the natural progression of life and often a peaceful reward for a long and fulfilled life.

Doreen gets a short course of antibiotics, an increase in her fluid tablets and regular paracetamol. She'll get a bed on the medical ward, probably next to Maude with the cellulitis and unstable blood sugars.

She'll get a full allied health assessment. If she's lucky, she'll get my favourite physiotherapist Katharine, who'll realise Doreen's biggest issue isn't a 15 metre decrease in exercise tolerance, but anxiety about falling. She'll be able to give Doreen some techniques to feel more confident and maybe even convince her to use her 4 wheelie frame more often.

General medicine is full of patients like Doreen. It might not be as glamourous as what I imagined myself doing in medical school, but it's what I've fallen in love with. We don't get the Wegner's granulomatosis patients or the rare endocrinopathies or even most of the STEMIs. In fact, we don't get anything that would have excited me at the start of internship.

What excites me now though is managing these little old ladies with 10 comorbidities. Everything exists on a balance beam and if you treat their heart failure too aggressively, their kidneys will fail. If you fluid restrict them too carefully, they become hypotensive. How do we balance the risk of bleeding on anticoagulation against the risk of stroke? How far should we investigate their iron deficiency anaemia? Is there a point in doing a colonoscopy on a nonagenarian? And how do we deal with a family who refuse to accept their mum isn't coping at home, or worse, refuse to accept that mum is dying?

Our bodies are an incredibly complex interplay of systems that depend on and influence each other. The heart can't function without the kidneys, a failing heart affects the lungs. General medicine requires you to not only master each system, but manage all the systems simultaneously whilst taking into consideration the psychosocial context.

There's a famous quote:
The emergency doctor views the patient through a telescope
The speciality doctor views the patient through a microscope
The Medical Registrar views the patient in plain sight.

Furthermore, you can achieve perfect control of a patients ailments in hospital but if you send them back to an environment where they are too scared to mobilise, too forgetful to take their tablets or can't cook, they are no better off than when you met them.

We might cure their UTIs or this particular infection, but general medicine isn't really about cures. It's more like when you take your car in for a service and they replace the oil, fix that strange leak beside the radiator, align your wheels and give the inside a good vacuum. That's what general medicine is about - making the most of what a patient has. The end point isn't a cure. The end point is getting the patient to the best level of health we can then sending them home with enough supports to maintain this, or sending them to a place where they can get extra help.

Some people call medicine a 'dumping ground', as by the time they are referred to the med reg, several of the speciality units have usually said no. I think that downplays the work the unit does. We've all seen the orthopaedic team take excellent care of a #NOF, but not notice the patient slide into pulmonary oedema. Or the cardiology team that saves the patients life but doesn't realise her bigger issue is that she can't cope with the stairs at home.

The truth is, for patients like Doreen, general medicine is the best place for them. She needs 'big picture' medicine. Her creatinine clearance means much less than her ability to get out of bed in the morning.

Maybe I'm not as hardcore as I was in medschool, but these days an adorable geriatric with 4 vague symptoms, functional decline and 10 comorbidities makes me more excited than a zebra diagnosis.
And let's be honest, Doreen, Maude and more than likely your grandparents, need more doctors who like me want to do general medicine.

Sunday, 1 December 2013

How to sit through a lecture on a condition you have

This is a lecture I wish I'd received at the start of medical school. It's one of those lessons I've had to learn by been thrown into the deep end and experiencing some of the most uncomfortable moments imaginable.

I hope this article means you wont be the student who leaves the lecture theatre crying, but even more, I hope it means you won't be the student who make a harsh generalisation about a condition that statistically someone in your classroom has.

1. Selectively disclose your condition

This needs to be judged for each situation. With full respect to the girl in my first year lecture who announced to the theatre of 300 people that she had endometriosis, I personally believe in disclosure to a small group setting is important but disclosure to large groups isn't always required.

I wish that being in the medical field meant there was no judgement, but I'm realistic. When you tell someone you have a condition, they will judge you on some level. I sincerely hope the majority of medical students will not change their opinion of me because I have depression, but inevitably some people seem to think having a mental illness means they need to walk on eggshells. Mental illness obviously is a 'high risk' disclosure, but all the same, your fear disclosing your Crohn's Disease or Rheumatoid arthritis is legitimate. You get a bizarre wash of sympathy and a 'chronic illness' label that you never asked for and don't know what to do with.

You need to weigh the risk of a negative reactions against the risk that someone makes an insensitive comment about your illness and really upsets you. I once witnessed a horrible comment about people with borderline personality disorder in a tutorial, knowing the girl next to me had that very diagnosis.

After much trial and error, my comment in (small) tutorials is this:
'Before we start I just wanted to say that I have depression. I'm not saying this to make you uncomfortable but I've seen people make generalisations about conditions not realising people present had them and I wouldn't want anyone to feel uncomfortable from a situation like that.'

2. Do your research

It might seem strange to read the textbook chapter on a condition you've had your whole life, but I promise you that you don't want to discover anything new in front of your classmates.

It's going to be a difficult class already, don't give yourself the extra pressure of having to apply new information to your life/ wondering if you'll be eligible for new treatments.

3. Focus on someone else with the condition

Remember this isn't a lecture or tutorial about you, even though that's what it might feel like. You're in this situation to learn how to one day manage a patient with this condition. Try to picture your future patient and apply everything you're learning to that imaginary patient.
You will compromise your knowledge for the exams if you use yourself as the patient you imagine with that chronic condition - you don't have every single symptom or complication and you can't look at yourself objectively. Invent your imaginary patient before the class and and at difficult times relate the topic back to them.

4. Don't resent the patients

On my clinical placements, I would sometimes get frustrated seeing inpatients who I perceived to be less unwell than me. It was particularly hard on days when I felt at my worst.
You aren't benefiting yourself or the patient if you have this attitude- be happy that this person has received help before getting to the severity you did and if you really do feel worse than the inpatients, maybe that's a huge alarm bell to get more help for yourself!

5. Don't take things personally

My third year class was shown a series of photos of perianal fistulae during a lecture on inflammatory bowel disease. As with many graphic photos, these slides were accompanied by groans and gasps of horror. We've all done it - the involuntary and almost expected reaction to graphic surgical photos.

Now imagine being the medical student with Crohn's disease in that lecture theatre hearing his friends shout 'that's disgusting'. How do you get through that?

It's not about you. Their comments are not about you. They would die if they knew you were sitting there taking this personally. They wouldn't react like this in front of a patient and they would never react like this towards you - it isn't personal and if it becomes an ongoing issue, this is one of the times to use point 1 and selectively disclose.

6. Be altruistic

At the end of the day, it's still difficult to sit through a lecture about a condition you have. You'll feel stereotyped and judged and there is no amount of reassurance I can give that will make you feel differently.

Before getting upset that your peers don't understand what it's like though, consider using this as an opportunity to put a face and a success story (you're in medicine after all!) to the disease. I spent many years upset that no one spoke about depression before realising that I needed to admit to having it if I wanted it to be something that was spoken about. I hope that there is at least one doctor from my med school who has a greater understanding of depression having listened to one of my speeches.

Remember that having a chronic illness in medicine can be your burden or your edge - it's your personal insight into the life of a patient. It can make you a more brilliant doctor if you embrace it.

Sunday, 28 April 2013

The truth about internship


I’ve wanted to be a doctor for as long as I can remember.

Not only have I wanted it more than anything in the world, I’ve given everything I have to get to this point.

Until you experience it, it’s difficult to imagine the sheer amount of knowledge crammed into our young minds at medical school, and the sacrifices required for that process. I’ve spent more Saturday nights with Talley & O’Connor than at parties, I’ve broken up with boyfriends who didn’t understand the hours and I couldn’t count the sleepless nights or cups of coffee if I tried. What got me through though, was knowing it would all be worth it when I graduated as a doctor.

So what am I suppose to do now that I’m finally here. Now that I’m finally living my dream, only to discover that it’s not that great.

This recent message from one of my favourite senior doctor tweeps hits very close to home: 



It’s hard to believe that the first year where I’ve not been required to study all night could be the worst.. but it is! Internship is an impossible job to be brilliant at. Can you imagine how that feels to a type A personality?! This is the first time in our lives that many of us have not been good at what we do.

By all measures, I was a great medical student. I knew the answers on ward rounds, helped my interns, enthusiastically scrubbed into surgery and did well on exams. I am not, however, a great intern, and I can’t see how I can become one. I am organised, early and care for my patients immensely – but there are so many things that are impossible to master about this job. For example:
  • A great referral will not change the fact many inpatient units have no physical capacity to accept a patient. The fact that these referrals are rejected due to system strains do not change that fact you've failed a task set by your senior. 
  • No amount of negotiation skills will change the mind of a radiology registrar with different beliefs to your surgeon regarding the appropriateness of pre-operative imaging. 
  • No amount of time or effort will change the fact that our hospitals are understaffed and overworked and it is with absolute horror I have realised no amount of overtime will allow me to be on top of paperwork. 
  • A good intern isn’t necessarily clinically impressive, but is administratively efficient – something understandably but inconveniently not focussed on in medical school
  • My skin will never be quite thick enough to deal with the bullying culture. 
I work for an amazing health service whose support far surpasses the stories I've heard from other hospitals. No amount of mentoring or support can change some thing we face. Interns are the bottom of the food chain in any profession, but this is heightened by the inherent bullying culture in many, if not all, specialities we rotate through. I’ve spent hours thinking about this and I honestly believe that most people don’t intentionally mean to bully the junior doctors – they are just unbelievably stressed and take this frustration out on those below them.

It’s interesting that all of our senior doctors have been through this and the culture remains the same. Certainly none of my colleagues are counting down the days until they are powerful enough to make some intern’s life hell. At what point do you start caring more about your career and conveniences than nurturing and supporting the next generation? Or am I too naïve to assume that all consultants started out as altruistic, scared interns just like me?

Of course, I am an incredibly privileged person to be writing such a blog post. Don’t think for a second I’m not eternally grateful for the opportunities and support that have got me here, or that I’ve forgotten how easily I might have been one of the thousands who missed out on a place at medical school. I truly adore spending time with my patients and love the idea that I’m helping to ease suffering in some way. Most of the time I do love my job and this IS still my dream, it’s just a little less magical than it was when I was a medical student...