Kate.

Dr Kate Granger MBE

Dear Kate,

I’ve never met you but my heart is broken.  I was a resident when I first discovered #hellomynameis and I remember reading your story and thinking how amazing you were, how suffering the blow of such a terrible diagnosis and at the same time, using your experience made something positive out of it.  I loved how much you loved medicine.  Your knowledge, the passion you had equally for the science and humanity of it; I remember thinking at the time, will I ever love this job that much?  I was burnt out and overworked by a giant, thousand bed hospital that had gobbled me up and chewed me into millions of tiny pieces.  I loved how you loved life, music, food, how you enjoyed all of it, in spite of it.  I followed you through time, all these years, to today.

When I became a registrar I had no idea what I wanted to do.  I figured a year of it wouldn’t hurt for experience sake and back then, I was so lost and confused by the brutality of the job.  And my first year of registrarship was a further baptism of fire that I wouldn’t wish on anyone.  Multiple personal tragedies, workplace bullying, and discovering what ‘clinical governance’ really means, more being gobbled up by the system, and int that year, being so lost I couldn’t speak anymore.  I kept following you, reading your tweets, feeling the dread that came with each infection, cheering for you when you got home.  Your love of life, of your marriage, your work, helped anchor me, helped me remember what was important in life.

Right at the end of that hard time, I did my first geriatric medicine term and like you, fell in love.  Suddenly I understood it.  It was all the best bits of medicine (for me), wound up messily with the culmination of human experience.  It was medicine, it was families, it was psychology, logistics, pain and suffering, healing, quality over quantity.  And finally, with a new purpose, that horrible year faded into memory, I got my exams and sailed happily into that world where I am now without one single regret.  And throughout that whole, torrid, journey, you were there on your own incandescent, heartbreaking, amazing, world-changing path.

I’m so sorry.  I’m sorry about Christmas.  I’m sorry Chris and God, so sorry about Charlie.  I’m sorry about the baking and the music and the little ones.  I’m so so goddamned sorry that your patients don’t get you as their doctor because you are who they need.  I’m sorry that thousands of people are championing your cause because I damned well know that if the cancer never happened there wouldn’t need to be the cause.  I want to wind back time for you, make the diagnosis never happen because you deserved your family and your career and all the cakes and Pimm’s and other nice, bright things in life. And you took all of that sorrow and turned it into magnificence, the highest form of functioning.

At the beginning of the year at my hospital in Sydney, the nurses had set up a table at the entrance and took photos of us in a picture frame adorned with the words ‘Hello My Name Is’.  We had name badges and wristbands and I wore them until they fell apart.  I’d been introducing myself properly ever since learning of you, not always perfect with it, but so much better than the at-times patriarchal way I’d been trained.  And these days it’s ingrained and it’s perfect because Kate, for you, I’ve practiced and practiced and practiced.  And early on I’ve been that scared resident that couldn’t look their cancer patient in the eye and since you, not any more, and since having my own interns and residents, I’ve trained them too and I know they’ll train all the others.

I love my job now Kate.  I appreciate the little things so much more.  I’ve learned so much from you and Chris, more than just introducing myself properly (and how sad we needed a campaign to teach us this), and forever more, for you, I will introduce myself, I will love my job, I will always try to look on the bright side of life and work with the hand I’ve been dealt.

The last thing I wanted to say, because I’m not sure you ever did, not publicly anyway because you’re a lady, was this.

Dear cancer,

Fuck you.

All of my love,
Another Kate.

Dr Kate Granger MBE and consultant geriatrician, passed away last night at the age of 34 from a rare type of cancer.  She was given less than two years to live at diagnosis, and in the five years that followed, sparked a worldwide campaign to have healthcare workers introduce themselves to patients, and treat them with the respect and kindness that they all deserve.  The #hellomynameis campaign has been adopted by hospitals and health facilities all over the world, and Kate and her wonderful husband Chris have raised over 250,000 pounds for the Yorkshire Cancer centre in Leeds.  Kate wrote two books in this time because she was clearly a spectacular overachiever, you can find them here.  She will be sorely missed by healthcare workers all over the world.

Decision fatigue and how I’m ending it.

When I was going through training for the exams last year, our director of training gave us a teaching session about decision fatigue.  I’d never heard of it before, but it’s a studied theory that suggests that the more decisions you make in a day, the more the quality of your decisions suffer.  There was a seminal study of high court judges that found if in court all day, with no break, their decisions became harder and more unjust by the end of the day.  If given a lunch break (heaven forbid!) their decisions remained more balanced.

Steve Jobs is the oft-raised example, wearing his signature black skivvy and jeans combination, simply so he would not have to decide what to wear every day.

Women have come to accept the ‘what will I wear today’ battle as if it’s normal.  The more organised of us will pick out an outfit and lay it out, but even that’s a battle of decisions, just at a different time of day.  And some days it’s a complete experiment and by mid-morning you feel uncomfortable and sometimes fat.  Some days you nail it.  Some days you feel like you picked out all your clothes in the dark, from the bottom of your wardrobe and want to hide away from everyone for fear they might notice you’re a massive battler.

In the last couple of months I’ve done an experiment on myself with this, because my life, my job, is so demanding.  On a work day I’m up at 6, trying to get dressed, trying to get my toddler dressed and fed, trying to get her to daycare on time, and then trying to get myself on time.  I cannot have the added luxury of mixing and matching and trying on outfits, but nor do I want to not dress well.  In Juanity Phillip’s A Pressure Cooker Saved My Life, she describes wearing the exact same pants and top combination to work, having gone and bought a variation of colours of the same top, and the same set of black pants.  The book is an interesting insight into the at-times disturbing struggle of a mother trying to work-full time and progress her career while bringing up multiple kids.  It is a vignette (I think) in what an unsupportive workplace looks like – if they’d had any heart at all they would have let her work a bit less because it is such a stressful read full of too many sacrifices, even if at the time it was supposed to be championing ‘having it all’.  (Hot tip:  There is no having it all because no one, not even men, ever did).

As usual, I digress.  I found even the idea of tops and pants too decision fatigue-ing so I bought dresses.  I bought long sleeved dresses that were a bit gathered from the waist down (I hate wearing tight or fitted skirts or dresses and if you have to suddenly do CPR on a patient – not a good look).  So my work uniform is now a dress, tights, and flats, although now that it’s winter, it’s now ankle boots.  I only have dresses that I’m comfortable wearing (translation:  look good wearing) so that I don’t need to try them on in the morning, I pull it out of the cupboard, throw on the tights and shoes, and done.  They’re all different because I need the variation.

Hair and makeup gets done in the exact same style, no experimenting (I can do that on the weekend) but if I’m feeling a bit shabby, big fake diamond earrings tidy it up a bit.

I feel like I’ve Marie Kondo’ed my morning routine and it truly is life changing.  I haven’t compromised my personal style (if anything, it’s a lot more pulled together), and when I get to work, I’m not frazzled.  Starting the day stressed is the worst and I don’t recommend it.

I’m still working on how to do this to the rest of my day, but I feel like the whole “I have no nothing to wear” shitfight is somewhat oppressive and by removing it from our day, it frees us up to focus on other things.  Of course if you have the time, and actually enjoy playing around in your clothes on a daily basis, please disregard, but for those who find it a grind, I hope this was helpful!

Code Blue: Vogue Forum

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In 2004 I was fresh out of my first degree, and had no idea how to function as an adult.  I had to buy a suit to wear to my first professional job, and had no idea about makeup, having schlepped around in jeans and skater-trainers for my entire teenage life and early adulthood.  I showed up to my job in ill-fitting, mix-and-match polyester and felt like the worlds biggest impostor.  A woman there took sympathy on me and introduced me to the Vogue Forum.  My world opened and changed and suddenly I was surrounded by women of all occupations and personalities and passions and it was amazing.  I learned how to buy a suit.  How to wear makeup so I didn’t look like I’d been hit with Homer Simpson’s slap gun.  How to argue for more money, change careers, buy a house.  I.  Loved.  It.  And later when I changed careers, there was more support, and even applause.  There were famous threads, famous users, and it was even in the news a few times.

And then it started to fade.  The post’s grew less.  The forum was redesigned and lost screen real estate.  Some of the most famous threads and users were deleted inexplicably.  We all got busier as our careers progressed.

Later on I had the privilege of being asked to be a moderator which I gladly accepted, but the combination of medical school and subsequent training with my own life stuff in between (and consequent total exit from the Internet for a couple of years), the soul crushing amounts of spam that had to be binned in the background, the time poor moderators, and the unfixeable things like the deleted users and threads and lost screen real estate all conspired against us and now it’s a graveyard.

Except I don’t want it to be a graveyard.  And somewhere in all of that, my moderator privileges remained.  And suddenly now that I’m part-time, I have some time.  Not a whole lot of time, but I have some to write, and interact, and stick up for people and posts from being deleted.  So I’ve decided to out myself as a mod – not one of the earlier ones with the cool and funny jokes, or the later invisible heavy handed ones, one of the newer ones who has so much to give back to the forum.

If anyone reads the forum, please come back.  If anyone reads this blog, give it a go.  I’d really love to pay it forward to the new generation of early 20 somethings who have no idea about the world.  I’ll make sure status-anxiety doesn’t result in the deletion of a $10 a week on food thread or any great arguments in the current affairs section get shut down.  Vive la Vogue!

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Restless for the still.

It is Monday and I am shaking as I walk into the tiny hospital where I’ll be doing my first term as an intern, in a criminally under supervised emergency department (which I’m since happy to report has improved in that regard).  I can barely open the door to the junior doctor’s room I am shaking so much, and I can barely open the locker I paid a $5 deposit for to put my stuff in.  At orientation I was told to bring common sense and two pens so I’ve travelled pretty light.  My clothes feel scratchy and uncomfortable because I had no idea what to wear.  A face appears from behind the lockers, a nice-looking older Asian guy and too enthusiastically I say “Hi! I’m the new intern!”   He smiles at me and says “I can tell”.  I am dying of terror.  My pass falls off on my way to the emergency department.  I drop my pens.  My pass doesn’t work, necessitating a trip to the bored-looking security guys who grab the pass, swipe it in something then give it back to me without a single word.  The first patient I see I spend a long time taking a history and doing an examination and thinking about the issues.  A little too long.  The in-charge doctor rips me a new one for taking too long and tells me to keep it far briefer.  I see a grand total of 3 patients the whole shift because I have no idea what I am doing.  I lose both of my pens during the shift and I’m pretty sure common sense didn’t come with me to work that day.

It is Monday and I am not shaking because it’s six years later.  It’s another new hospital, another job because every 3 months we get a new job.  Often a completely new workplace.  New bosses you don’t know, new colleagues you don’t know, new patients, maybe a locker, maybe not, no idea where you’re going to keep your stuff because doctor’s who aren’t consultants don’t really get offices – they might get a room with computers but it’s shared with nurses, physios, allied health.  You sure as hell don’t get your own phone or computer.  Sometimes you stick your bag under the desk and cross your fingers.  Today I am carrying a semi-expensive handbag and my clothes match, my shoes are shiny.  Again my pass doesn’t work and again I return to security and play on my phone wordlessly while they wordlessly fix it.  My bag is neatly packed with ten pens, a pouch with my neurology tools, a stethoscope, an attractive leather-bound notebook, Mecca’s lip deluscious (AMAZING), my phone, keys, and wallet.  Switchboard has no idea who I am when I pick up my pager, we shrug and joke about workforce, and I go and meet my new set of faces, new bosses, colleagues and patient’s.  I easily get along with everyone, after this long in the game, there’s no point being cold and the sense of relief among us all is palpable.  Oh good, not with assholes this time.  I ask the nurse in charge before I start if there’s anything previous doctors do that piss her off so I can avoid pissing her off, and when the consultant comes for a round, I ask him to tell me how he likes things written and done.  I make mistakes.  I forget to fill in a form.  I get their names mixed up.  It’s the first week, I’m okay with it.

And on it goes.  New job, new people, every 3 months.  For six years.  By the time you’ve gotten to know everyone and your job, by the time you’ve earned their trust, it’s time to move on again.  At first it’s exciting.  Moving around, meeting new people, entraining yourself into a specialties mindset.  But the last 2 years it’s a grind, that perpetually semi-forgetful state bred out of a permanent state of unfamiliarity.  And lately I’ve felt envious of the bosses and senior nurses who know everyone and each other so well because they’ve been there for years.  Years!  Can you imagine in it?  Being in the same job for years?  Not having to move home, to find a new route to work, where to put your lunch?  Not having to reapply for jobs every year?  I almost can’t.  And I’m restless for that permanence.  The argument for this of course is that it broadens your experience and it really does.  It’s a good thing because while it doesn’t make you an expert, it teaches you to ask the right questions.

The good thing about being post-exams is that now at least I’m able to concentrate all those new jobs and workplaces into an area I like instead of all areas.  I’m at 4 different hospitals in vastly different locations this year and I don’t mind so much because they’re all in geriatric medicine but I’m getting tired and very very restless to start standing still.

Why would anyone choose medicine?

It’s been a very long time since I made the decision to switch careers and study medicine.  I still remember the day of that decision so clearly.  It was a sunny Sunday morning in September, the kind with that newly warm air that signals winter is almost over.  That wind that brings excitement and promise and a sense that everything is going to be okay.  I sat up and proclaimed to my future husband that I was going to do medicine.  I can’t remember his response.  I just remember it striking me like a bell.

The lead up to that of course, was all the stuff of life, a job that I hated, a personality that didn’t fit with it, a less-than-straightforward childhood, a friend who suggested medicine.  And at the time I found it so hard to quantify why I wanted to do it.  It was medicine right?  Who wouldn’t want to do it?  Wasn’t it the pinnacle of everything?  That noble field of saving lives that came with the added bonus of sounding impressive to everyone you met.  And sure, I didn’t mind anatomy!

Oh medicine, if I knew then what I knew now.  I’m not going to tell you I was naive and that I hate my job.  I don’t hate my job.  And everyone is naive when they enter anything.  What I will tell you is that medicine took my innocence about people away.  The world I lived in then is so different to the world I live in now and some days I would give anything to go back to that.  Things happen to people that you didn’t know could happen to people.  People do things to people that you didn’t know could be done.  And you see things that you can never un-see, that change you forever.  Those days of innocent hobbies and social lives are gone, replaced with long hours, and soul draining sights and stories.

In time it gets better, your soul gets less drained, the stories are carefully compartmentalised into what is in your control and what is not.  But you get harder.  You become the person who was insensitive toward you once upon a time, and not because you don’t care, but because you’ve simply seen so much horror, that your threshold for what truly hurts is way above everyone elses.

I wanted to help people.  And to some extent I do.  But in hindsight that wasn’t specific enough.  Help people how?  People need so much more from other people than a plaster of paris or a prescription for tablets.  Would I have chosen a path that helped people be healthy and happy if I knew what I know now?  Because a huge proportion of the hospital aren’t there because they want to be healthy and happy.  Which population group do you help?  Those that want to be helped or those that don’t?

If you’re thinking about why you want to do medicine, don’t go and ask doctors why they like their job.  Ask them how medicine has changed them.  See if you want that for you, and if you do, go for it.

How to get a job as a basic physician trainee.

A commenter requested this and I thought I’d write it up because a) it’s helpful to people who want jobs and b) it’s a bit of insight for the non-medical into what you have to do in medicine to become a medical specialist.

First you have to decide what you want.  I went into the program with no idea what I wanted and came out of it completely set on what I wanted.  It’s okay if you don’t know.  I was of the opinion that a year as a medical registrar was good for the resume for pretty much everything else and I stand by that opinion.  Many will disagree and that’s okay.  I’m someone who has always operated on gut feeling and something drew me towards it.  But if you’re defaulting into it for whatever reason, I urge to try a bit harder and do what you really want.  Every year there’s at least one person who pulls out completely traumatised.  Don’t be that person.

Step 2.  Your resume.  You put your name and address, your education details (your degree/s) including extra-curricular stuff and honours, followed by a list of the rotations you’ve done to-date.  That’s page 1.  On page 2 you need the following headings in the following order:

  1. Teaching experience
  2. Quality assurance
  3. Committees and representation
  4. Awards
  5. Professional development
  6. Publications
  7. Referees

This is the order in which the selectors will weight your resume.  1 is self explanatory, 2 is how you have contributing to making sure the hospital achieves a high standard of quality and safety.  Audits are the best way to demonstrate this, and the fastest way to get an audit is to offer to audit the DVT prophylaxis on your ward.  Or do a handwashing audit.  I know it’s doesn’t sound fancy but it doesn’t need to be, it demonstrates you’re committed to safety.  Any morbidity and mortality meetings that you have participated in go here (non-medical people, this is the meeting where the very occasional bad outcome is discussed and everyone makes a plan to make sure it never happens again), and any talks you’ve done to your colleagues on patients with conditions that no one knows a thing about because they never happen.  3 is important, join a committee!  Have opinions!  Pharmaceutical committee, computer systems committee, accreditation committee, RMO association, just join one and show up to their meetings.  Put that on there too.  Professional development is conferences and courses.  Try to get ALS2 done before interviews (not always possible, I didn’t).  Go to some weekend radiology courses, do an online course, it shows you’re committed to studying.

Note that publications is actually pretty low down the list.  I know it’s different for other specialties but for basic training the focus is so heavily on you being safe (because you’re given a LOT of responsibility), and you getting through those rotten exams that at that particular point in time, they’re not as crucial.  (Note for advanced training they can be pretty damn important though).

For referees, try to put 3.  The online system wants two from memory, but medicine is a small world and the selectors DO ask around to get a sense of you.  Secondly when choosing a referee, don’t choose the Professor of Everything Prestigious if they hardly know you and you’re not mates.  They will give you a balanced and fair assessment.  Except no one else is putting up referees who are going to do that.  They are putting up referees who rightly or wrongly are giving them straight excellents and writing stuff like ‘they are amazing at everything all the time’.  So I’m exaggerating – but only a little.   The problem for the selectors is that they KNOW that this goes on, but they can’t justify picking the candidate with the fair and balanced assessment over the one with the straight excellents even if they know it’s untrue.  It’s there on paper and they have a hard time explaining it to admin if anything ever goes wrong.  So choose the referees who like you as a person and you get along really well with even if they’re not the amazing Professor of Everything.

The next step is to tee-up pre-interviews.  You may have strong opinions on these, most people do.  But the truth is, selectors are of the opinion that if some people do it, and you don’t, they are going to go for the people who do because they’ve tried harder than you.  You don’t need to do this for every single hospital.  Do it for your top 5 or 6.  What’s that?  5 or 6?  Yes.  Do not assume your hospital will keep you.  Too many people got burned last year.  Apply widely.  They’re not allowed to ask you what your number one is at interview.  The least terrifying way to organise a pre-interview is to email the MESO (Medical Education Support Officer) and ask them to meet with the DPT or NDPT (Director of Physician Training/Network Director).  They’ll arrange a time to do this.  You go and meet them for ten or fifteen minutes and have a chat about their network.  Read about their network first.  Don’t ask them what the hospitals are.  Don’t ask them anything you could have read yourself.  Ask them things like, ‘what are you looking for in a candidate?’ And ‘where have your candidates gone after BPT’?

After that apply online to everywhere you want to go plus a few places you don’t.  For the selection criteria you must use examples.  Prove you are what you say you are.  Don’t waste 100 words or whatever it is saying how great you are – why should they believe you?  Use clinical examples wherever possible.  Ask around about good networks to go.  Don’t focus solely on pass-rates, nowhere gets 100%.  As long as they’re with or above the national average you should be okay.  Make sure you turn up to the information nights but don’t feel you have to bomb the DPTs/MESOs with questions like everyone else.  If you can manage a ‘it’s nice to see you again after the pre-interview’ or something, that’s great.  If you really really really really want that hospital then sure get in their face.  They take attendance at the info night and they do check that you attended.

Once you get your interview offers do the following.  Do the places you want least first – they make good warm-ups.  Refer to your pre-interview IN the interview and refer to the information night you attended as well.  Ask a few questions at the end.  I can’t comment on the content of the interview, most places ask different questions and they change every year so I recommend asking people currently at those hospitals what they asked the previous year.  Before the interview have a look at the major publications of the DPT and the NDPT, and try to comment on them if you’re interested in that field.

What are the selectors looking for?  They want to know that you’re a safe, nice doctor that they would be comfortable with looking after their husband/wife/mother/grandfather.  They want to know that you’re not going to go blank or crumble under pressure.  That you know how to study for a high stakes exam.  They’re not looking for BPT-level knowledge.  You do get a clinical scenario in the interview but it’s BLS/DETECT level stuff which I recommend reading but don’t go in there thinking you have to prove your knowledge, you wont do that well.  They want competent, caring, focused, and cool.  The knowledge they can teach you.  The other stuff takes a psychologist (which you may want to consider if nerves are a problem for you)!  You can change your preferences after your interviews.  I had my heart set on one hospital but during my interview (and pre-interview actually) for another, I got along with them so famously that I changed my preferences afterwards.  And got that hospital.

That’s really important and probably why pre-interviews ARE a good idea.  They allow you to see beyond a name and a reputation, and work out where YOU click.  Your life will be so much easier if you click with your colleagues and seniors, rather than force yourself into something you’re not for the sake of a name.  Really important.  Go with where you fit in, not to a place where you have to fit yourself to their culture.

I hope that’s helpful, it’s nice to write it all down and I’ll be directing my residents here also.

That conversation.

My first rotation in my newly chosen specialty (Geriatric Medicine) is on a ward with a policy of not-for-resuscitation.  I really hate that term.  It’s so loaded, so weighted with the implication that we’d just give up.  The context of this current job is that my patient’s have such severe dementia that they’ve forgotten their families, how to use a fork, tie their shoelaces.  If they were to die from natural causes, say a heart attack, our policy is that we should not attempt to restart their heart, or put them on machines that breathe for them, for the simple fact that it wouldn’t cure their heart problem (there is no cure for old age), certainly not cure their dementia, and cause a lot of pain and suffering for an outcome that at best, would give them a few more, horribly painful days of life.  The alternative is if that something catastrophic were to happen, instead of doing things that would achieve nothing but pain and suffering, we would change our goals to prioritising comfort and dignity.

I am at the start of a conversation that will define my career, and one that as a society we are in the process of defining.  I am loathe to go into the mechanics of what happens in these situations.  They’re traumatic enough for trained personnel.  In the movies and television, there’s about a 70% success rate if you get CPR or shocked with the paddles, or go into ICU on a breathing machine.  In reality, it’s about 20%.  If you’re young.  If you’re over the age of 80, it’s close to, if not 0%.  And yet so conditioned by the media are we, that we hold onto the hope that our loved one will be the magic one, the one that proved the doctors wrong.

So even when I have the discussion with the family members of the patient with advanced dementia, a barely functioning heart, and that near-0% success rate, they still tell me to ‘do everything’, to save their loved one.  But I can’t.  I can’t save them.  You can’t cure ageing (yet) and you can’t cure dying of old age.  Sometimes I’m successful in explaining these principles.  The principles of goals of care, of ‘doing everything’ for anything we can absolutely cure, for not ‘doing nothing’ when we can’t.  We never do nothing.  One of my favourite professors once told me that as doctors sometimes we use medicine and surgery to treat problems, sometimes we use morphine and ice-cream.  The opposite of ‘do everything’ is not ‘do nothing’.  It’s ‘do something else’.

Which brings me to ‘comfort and dignity’.  What does that even mean?  I say it a lot at work, because it’s a goal that resonates.  The mechanics of comfort and dignity is that if Something Bad happens, instead of trying to fix the unfixeable in desperation and poor judgment, we fix the symptoms instead.  If the Something Bad causes pain, we give pain relief.  If it causes distress, we give relaxing medication (similar to Valium), if there are other symptoms, there are things we can do.  The end result of going through that sliding door instead of the other, is a loved one, peaceful in bed, in no pain, and sometimes able to talk to their loved ones in their last hours-to-days.  This is in stark contrast to the CPR/breathing machine situation.  Stark contrast.

I want to be clear that this is not euthanasia.  Euthanasia is a complete can of worms which at this point in time is a dogs-breakfast that I don’t wish to visit.  But symptom-relief and subsequent dignity I’m a big fan.  It doesn’t hasten or bring on death, the underlying disease does that all by itself.  But it does make the path there a lot less traumatic for the patient and their loved ones.

I’m so far down the rabbit hole of medicine these days that sometimes I forget that I’m using jargon.  It’s hard to know if I’m losing my patients families when I have this discussion because 99% of the time they’re so polite.  And yes, it’s my job.  There’s a form I have to fill in with a families plan for their loved ones passing.  I don’t want that to come across when I have that conversation.  I’d love to hear some reader’s experiences of death and what was done well and what wasn’t.  This is a conversation I’m going to have a million times over for the rest of my carer and I want to get it right.