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.

What to Do When… #1 (A cheat sheet to residency)

Forgive the incoherent title, it’s late and I’m tired.  But now that the new juniors have started, I thought I’d share some tips to not letting the shit get you down.  So for my inaugural what to do when, I thought I’d talk about….

What to Do When Someone is an Arsehole to you on the Phone.

(Yeah I can’t capitalise, I’m so tired I can barely see).

Okay so you’re calling for a consult or your calling the radiology reg.  These are the most likely two circumstances in which someone is going to be a complete prick to you.  Some hospitals give out awards for blocking consults or reviews.  Down the phone their tone is dripping in sarcasm, they ask if you’ve considered this clearly obvious thing which had never even occurred to you, your self esteem is in your shoes and you’re trying not to cry because you’re so stupid you should never have done medicine right?

Wrong.

You never considered that thing because you’ve just finished medical school in the last one or two years.  Or maybe you never learned that thing.  And also you’re not psychic.  And also you’re calling for their expertise, they’re not calling you for yours.

So #1, you’re not psychic, and you’re not stupid, they’re just being an arsehole.

Then they say “what’s your name, I’m going to have to tell my boss about this”.  That’s it. You should quit right now right?  You’ve been found out.  You shouldn’t be there.  You’ve been an impostor all along right?  Wrong.  Wait for it, waaaait for it – they’re just being an arsehole.

#2.  They don’t know you.  No really.  They’ve never bloody met you.  They have no idea who you are, what makes you tick or what you eat for breakfast.  So threats to tell your boss and eat your firstborn because you’re clearly incompetent are just hot air.  They literally don’t know you.  Anyone who tries to judge your performance from a 30 second phone call is demonstrating their own incompetence.  Assessment takes time and repetition, you need to demonstrate progression – it is not what happens in a phone call the first time you speak to someone.

Then you inevitably get some set of demands about how they can’t believe you don’t know xyz, what their cat ate for breakfast 6 years ago, and the knife through the heart…you should know that.  The most useless phrase in medicine.  People who say this are simmering angry, they’ve got so much shit going on that they have no insight into that it comes out in this ridiculous way.  No you shouldn’t know that.  You’re ringing them for their help.  You might not be serving up what they need on a plate, but you’re ringing someone for help.  And when someone in a position of power gaslights, intimidates and says ‘you should know that’ to a person in a much more junior position, not only is it an abuse of power, but wait for it….they’re an arsehole.

#3 You’re ringing for their help and expertise in the care of a patient.  Don’t be afraid to remind them of that but don’t take it as a moral failing that you didn’t have all the information.  And if it was something simple, like maybe you forgot to get the HBa1c for an endo consult – don’t beat yourself up.  Apologise and say you’ll have it for them and move on.  If they go on about it – they’re an arsehole.  And they will.  But if you’re the sort of person who learns from their mistakes (like, you know, most people), you will have it ready for next time and that’s how you know you’re good at your job.

And then you get to ‘well I’m not coming to see the patient until xyz is done’.  Alright there champ, commit to having to take two phone calls.  One of my biggest lessons as a registrar is just see the patient.  You don’t need all the information, just a good clinical question and some background and a request to the caller to find out some more for you.  That’s it.  Anything beyond that is just mucking around.

#4 Get the info and call them back.  You’ll have learned something and they’ll have just created more work for themselves.

And finally, you get off the phone feeling really crappy.  You feel like a failure, you feel down in the dumps, you can’t even articulate all the thoughts behind your feelings.  It affects your work and everything seems to slow down while you battle with your unconscious brain and all the feelings it’s having in the background.

#5 Phone a friend.  Find a trusted person (not the competitive person who will also gaslight you and tell you they have no problem getting consults).  You will inevitably find that the person who gave you a hard time over the phone, gives everyone a hard time over the phone and is reknowned for their behaviour.  Bullies never operate in isolation.  If your workplace has an anti-bullying reporting service I highly recommend using it.  Nothing will get done off a single complaint and that protects people from spurious complaints (some people think getting feedback is the same as being bullied – it isn’t), but slowly and over time, as complaints collect, those slow grinding wheels of medicine move into place and the person either gets the help they need or get moved along.

But just know that when these things happen – it’s not you.  No one deserves to be treated with disdain at work, no one deserves to be barked at for not having all the details – even if it’s a recurrent problem, it needs to be dealt with in a formal way via a supervisor meeting, not belittled down a phone.  Expect better from your workplace.  This isn’t about whoever is the smartest wins.  This is about who cares the most about their patients and colleagues wins.  That’s what gets you the job you want ultimately.  People trusting you to look after their mother.  If they see a complete arsehole to a junior, they’re going to assume that’s how they behave to everyone – including patients.  So don’t accept that behaviour, and don’t ever engage in that behaviour.

I hope that’s not too heavy handed and angry, and I hope even more that it cheers a few of you up.  💖

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.