Heart of stone.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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3 comments

  1. Thank you for having the courage to articulate the serious flaws in the system. As an intern having come to medicine from a corporate industry I have found it profoundly disheartening and defeating how antagonistic the hospital system is. Medicine eats their young.

  2. Thank you so much for writing this so articulately, beautifully, and hitting so many nails on the head. I read it today and it was such perfect timing, when I’m finding myself aspiring to be the “good registrar”, and wondering if I need to care less, absorb emotions less, in order to FEEL LESS and be able to get on with studying to pass exams and trying to stay sane for myself and loved ones. I’m still not sure what the answer is, but thank you for making me feel human and understood.

  3. that my friend, is why I chose to do pharmacy. I think the environment is definitely better than being around a consultant/ specialists. I have lost count of the times I got yelled at for double checking a threefold increase of prescription medication, only to have patient suffering from side effect and returning to hospital.

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