Author: Bake, Love, Run

I came here to chew gum and kick ass. And I'm all out of ass.

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.

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Art, science, medicine, outrage.

I’ve seen come (and might have weighed into) some disturbing arguments on Facebook lately.  Things like cannabis oil being the magical hidden cure for cancer that millions of doctors, pharmacists, researchers and evil Big Pharma corporations are part of some sort of conspiracy to prevent the ‘truth’ coming, anti-vaccination, and so on.  And what I’ve observed is the complete inability of both sides to appreciate the thought process behind the other.  It’s like watching engineers try to communicate with graphic designers.  Painful.  There’s a lot of layers there, complex layers of emotion, past experience, fear, anger, guilt, and shame.  There’s a lot of shame.   One argument was that they would not be ‘blinded by science’ or science’s ‘big words’.  It was telling.

I’m in the somewhat unique position of being someone with an arts degree, a degree in medicine, and a parent who died of cancer, trying desperately after all treatment had failed to cure themselves with the magical cure du jour (Essiac if you’re interested).  The parent’s death happened first, followed by the arts degree, and finally the medical.  And sitting back and observing these raging blistering arguments on Facebook, worse on Twitter, has really got me thinking about just how far apart the fields of art and science have been driven, and how both have been siloed so much, that neither has any appreciation for the other, when they’re more intrinsically reliant on each other than most realise.

In my arts degree, I learned the power of the argument.  If you have a thought, and it’s plausible, you can argue your position until people agree with you.  You can redefine anything, that is postmodernism, you can question the meaning of everything, you can change it’s meaning if you want.  Gender is no longer a word that means male or female for example, and given the addition of social media to postmodernism, anyone’s opinion and definition is just as good as anyone elses, so long as you can find other opinions to back yours up.  And of course you can.  This of course, completely throws out respect for expertise, for process, for the years of honing ones craft that is science, or law, or engineering or medicine, or fine art or any of those things that suck you into a black hole of effort for years, only to emerge alone in a sea of Facebook opinion without any understanding of that process.  I think back to all of my essays, thousands of words of beautifully crafted arguments, backed up by leaders in the field.  All HD’s.   Your opinion is as valid as everyone who agrees with you.  You can use anecdotal evidence, indeed you’re required to, individual arguments are much more powerful and hard hitting.  It’s how the social sciences department of Wollongong University got an anti-vaccination PhD through – it wasn’t scientific, they could argue whatever they wanted and once backed up, it was valid.  It’s easy.  And it has a role.  Post-modernism has been wonderful at questioning those oppressive cultural norms, at deconstructing them and asking the hard questions of who we should be as a people.

When I started my medical degree, I’m a little ashamed to say that I had very little understand of the scientific method.  I would say that most people don’t.  I had to bring my year 10 level science up to scratch for the GAMSAT and that was painful and confronting.  There was shame.  It was the root of those ‘blinded by science’ arguments because studying science when you’ve grown up in an environment and culture that tells you that you can’t possibly be good at it because you’re a girl, feels like wearing a bikini in a blizzard surrounded by people in snowsuits.  It’s uncomfortable and painful and for me it was embarrassing.  The scientific method actually describes a process and it is the process of creating a fact.  People seem to get opinions mixed up with fact, as if one something happening to one person somewhere in the world can be ‘proof’ and not just a statistically random event.  How could you possibly tell the difference if you had no idea that a process existed?  And most really don’t.  The scientific method and the postmodernism argument actually have the same first steps, but science continues where postmodernism stops.  You have your opinion (your theory), you do your background research to see what has already been explored for that theory, and then you construct your argument (your hypothesis).  Postmodernism ends there.  What science does, is take that hypothesis and challenges you to carry out an experiment to prove or disprove it.  There’s the major difference.  There is supposed to be an impartiality there – you don’t emotionally invest in your hypothesis, the true unfeeling scientist does not care if it’s right or wrong, they just want to prove it either does or doesn’t exist (I say supposed because we’re all human and we all emotionally invest).  If your hypothesis was that gravity pulls you toward the earth, you could drop 100 balls from a height and argue that they would all fall down to the ground.  And so they do.  Your hypothesis is proven.  The next step is to then communicate your results, and crucially, other scientists then have to repeat your experiment and get the same result.  That is how a fact is born, a drug is made, an intervention realised.  And on the subject of drugs – first you have to prove it in a petri dish, then in an animal, then in an animal more like a human, then in a few humans, then a few more, then a lot more, and then others have to prove it, and after it’s on the market it has to be followed up and side effects reported into a register to make sure you didn’t lie about the whole thing.  This is done to avoid killing or harming people.  It takes 10 to 15 years and involves hundreds, if not thousands of people.  Watching the Charlie Gard case, where a doctor, a medically and scientifically trained doctor, offered a ‘treatment’ that was nothing more than a hypothesis, gave me chills.  It was my medical degree that taught me about process, of due diligence, and how gravely important these things are.

The chasm between the two fields grows greater every day.  I’ve had anti-vaxxers direct me to books by scientists and doctors, weighing into the ‘conspiracy’ for the great price of $29.99 (at least someone is making money), well written, plausible sounding books, all by scientists who appear to have completely forgotten about everything after step 3 of the scientific method.  There are so many vested interests, so much money changing hands for this crusade, and I am yet to see who benefits.

I think back to my father, desperately steeping that stupid tea into bottles and I get it.  I got it well before I ever did medicine.  You can’t use science and impartiality and common sense against the weapons of grief and loss and shame and fear.  Those feelings need to be named, the backstory needs to be understood before you can even start to have the realistic conversation, if you can even have it all.  I think to all the family meetings I have, day in day out, where I break bad news, where I tell people it’s not safe for their parent to go home, that they have a terrible progressive disease and no one wants to hear it.  Who would?  I don’t argue, I don’t respond with Facebook style outrage.  I acknowledge the fear and the pain.  I stay silent while they rage.  I tell them I’m sorry.  I don’t push the facts on them.  They stand silently on their own, proven by blood tests and brain scans and screening tools.  I think about those Facebook arguments, so fraught, so filled with outrage, so many complex layers of emotion – people’s backstories playing out through the lens of the argument du jour.  So much lack of understanding on both sides of each other’s process, how they came to be where they are and of who they are.

Barack Obama said in one of his final speeches, to get off the Internet and argue in person.  He was right.  You can’t truly explain your position, on why this is so emotional for you on social media.  One thing I learned in my arts degree is that ‘the medium is the message’ (McLuhan) – which means that it’s not just the content of the argument that is being conveyed that is the message, but that the medium which is being used is too (and he said this well before any meaningful social media).  Facebook, in spite of using real names, teaches us distance from each other, it teaches us mass outrage, mass bullying.  That if you have an opinion, be prepared for abuse and humiliation, of people shouting you down.  You internalise that message and carry it into the world and feel isolated and afraid as a result.  And in isolation your opinion starts to become a fixed and unmovable belief, often to the extreme.  And you find others within that extreme, people who ‘get’ you, so you’re not isolated anymore.  It’s us against them.  Except what you don’t realise is that everyone is doing it, just in different sets of fixed beliefs.  No one is much different.

So that’s my opinion.  None of it is fact, it’s mostly just observation and can easily be argued with.  What I’ve realised from all these observations is that we need to get the f*** off the Internet and get back into our world and talk to each other, without the backup of a thousand Internet bullies behind us.  Scary isn’t it?

You have to find the bright side.

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

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

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

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

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

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

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

Looking at life.

I was reflecting on my very long time online last night, made possible by a random sequence of events in the mid-1990s.  Those days are very long gone, as is the Internet as it was back then, it hasn’t really been archived and these days it feels a lot smaller, and a lot more corporate.  Gone are the days of it’s existence largely as a scientific information-sharing service, largely populated by enthusiastic geeks.

I thought back to my old blogs (also long gone) and how so much of what I wrote about was the day to day life of a twentysomething uni student, all the music I liked, and hobbies and random things.  It’s so easy when you’re a doctor to live that role when you get home from work, but of course, if you let that happen, when retirement comes, you might as well scoop out your soul and leave a shell of yourself.

So here is my proof that I do things other than medicine.  I do things.  Like, go to the aquarium with my daughter who has a natural affinity with penguins.  And they with her.

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I also work on my home, which we are not into a year of owning and like to bemoan how poor we are.  Like gardening.  Attempting gardening.  See the dead grass?  It died in a very neat line along the length of the fence.  If you look over the fence, the neighbours have done some gardening of their own.  Just saying.  This is an orange tree.  I hope.

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You may not know that I am a Swarovski addict.  I don’t care what anyone says about it.  It is sparkly and stays sparkly.

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I am also a big fan of high tea with friends.  I like to work my way through high tea venues in cities.  Where else can you legitimately drink champagne and eat cakes without anyone getting judgy?  This one had an all you can eat chocolate bar after the scones and whatnot.  It sounded good in theory.  It is a double edged sword laced with delicious poison.

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Meanwhile I continue to drown in college requirements and oddly sexist comments about part time doctors but what can you do?  Work finishes, and the cake awaits you on weekends.

 

Ten things everyone should know about geriatric medicine.

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

Guts and glory.

I’m doing an outreach rotation at the moment.  It involves venturing into the community, leaving the bubble of the hospital, and assessing people to see if they need to go to hospital.  The idea is that if we can treat them in the community, we can prevent a hospital admission.  Hospital admissions are expensive, and for the group of patients I now work for, usually detrimental too.

Except that when you’re in a hospital you have everything.  You have a lab at your disposal, imaging, on-the-spot specialist opinions if urgently required, you’re surrounded by experts.  Out in the community it’s me.  Me and my stethoscope and doctors bag that has antibiotics, diuretics, and a script pad.  If I’m lucky a nurse will come out with me – the nurses I work with are for more experienced than I, they’ve been doing this gig for decades and before that, working in intensive care or emergency.

When I see my patients, I have to ask myself, what is the best for them?  Is it a hospital admission?  Is it prevention of a hospital admission?  Is that safe?  If I don’t send them to hospital, will they survive their ailment?  If I do send them to hospital, was it the wrong call?  Have I created illness for them, have I wasted thousands of dollars?

Last week I saw an elderly woman* who was delirious.  She’d had some blood tests a couple of weeks back which were helpful for me, but had been well in between.  Delirium is a hard one because my patient can’t tell me what’s wrong.  My patient didn’t have any pain (that much you can more-or-less elicit) and she had a catheter for her urine, the contents of which at a glance, was clear.  I gave her some juice and she vomited it immediately.  I examined her in a limted way – she couldn’t follow a single command and I couldn’t find any signs of infection or much else for that matter.  No medication change.  For all I knew it could be a non-medical reason, sometimes simply a change in staff, a change in bedroom, can cause a delirium in our older patients.  She was dehydrated.  The nurse offered to hang some fluids and I agreed and asked her to collect some bloods and sat down to write my notes.  I wasn’t keen to send her to hospital, surely I could figure this out, institute treatment, and keep her out of hospital.  But something was bugging me.  It was her colour.  People can take on a different tinge depending on what is wrong with them.  There is the yellow of jaundice, the flushed of infection, the mottled of sepsis, the pale of anaemia.  The greyish-yellow of uraemia (from kidney failure).

A million years ago I did a term as a renal (kidney) registrar.  It was easily the hardest term of my life, the level of responsibility given to me, given my junior level.  I wont go into details here.  But while it broke me, it made me, it taught me about guts.  My consultant at the time was a kind genius.  He would walk through the emergency department, and collect patients.  They would be admitted under other services but because he’d worked there for twenty years, he knew the whole community and wanted to look after them.  The other registrars would joke about never letting him go to the emergency department or you’d have the biggest round list in the world!

My genius boss, who knew everything and who loved people, used his gut a lot.  When faced with a problem he didn’t know the answer to, he would stand there for what seemed like an age, hand on his chin, and then eventually say “I think we should try this…” He never got it wrong.  It was wonderful to watch the 40 odd years of experience he had at work.  He never really articulated why he chose that and I’m not sure he could, it was just the weight of that experience influencing his gut.  I’ve always found this hard.  Especially in the exams.  There’s so much noise in your mind as you go through.  If you choose this, what about that?  What would others choose?  If you get it wrong does it prove you are as stupid as you suspect you are?  If you fail, what does it mean?  Does it mean you’re a terrible doctor, does it mean everyone will look down on you?  Isn’t that the right answer as well?  The answer is lost somewhere in all of that.

When the patient is in front of you, it’s even harder.  It’s none one of 5 options anymore, it’s 50.  My patient could have had a stroke.  She was delirious, she couldn’t swallow properly.  If I didn’t send her to hospital, was I missing a stroke?  I didn’t think it was a stroke, but it could be.  How would I know?  I sat there staring at my notes for a really long time.  I had no blood tests.  I had my examination findings, my history.  I had that strange colour.

The nurse returned.  I took a deep breath.
“I’m sending her to hospital.”
The nurse blinked in surprise, a little bemused.
“I think she’s uraemic” I blurt out, “I’m not a hundred percent sure, but if we send the bloods and wait for the results, and I’m right, she’s not getting into the hospital until 9pm and no one senior is going to see her for a while.”
“Your choice doc”.  It may seem a benign statement, but my wonderful, experienced nurse who knows far more than me, isn’t arguing.  And if they’re not arguing, you’re probably right.  But still, if I’m wrong, then I’ve put a lady through a lot of unnecessary and painful intervention, and cost thousands of dollars to a very stretched system.  There are so many points at which I could second guess myself.  So many wrong calls.  This could be a completely wrong call.  It would be so easy to talk myself out of it, go with inertia.

We organise an ambulance.  I ring the emergency department consultant.  They are never pleased to hear from me but we keep it polite because we both get it.  The nurse and I run the bloods back to the hospital ahead of the ambulance to expedite the patient through the department.  I call the patient’s next of kin and explain, they are accepting.  And then I move onto another patient and try to put it out of my mind.

Later in the day when I’ve returned to the office, the nurse claps a hand of my shoulder.
“Nice call doc – good to see you trusted your gut”.  She thrusts a printout of the blood test and brain CT in my hand and there it is.  Severe kidney failure, no (obvious) stroke, right call made, correct treatment and admission commenced on arrival.

When I was more junior, the glory would have been in making the right diagnosis.  There is no glory in this for me now, because it’s a horrible situation for the patient.  I’m glad that things were done correctly, but the glory is in the trust I afforded my own judgment.  It’s easy to make decisions when you have a lot of information available.  Out here, in the far reaches of the medical galaxy, it’s so different, you have so little at your disposal.  So my post tonight is a little bit of a pat on the back for me because you don’t often feel successful in this gig so that when you do, you’ve got to take a moment to enjoy it.

But as always, I have a point to make.  Exam sitters, when you take that exam on Monday, trust your gut.  When you have that moment when you think “I think it’s this but I’m not sure why”, no matter how faint that moment is, and no matter how much your mind tries to convince you it could be the other 4 options for so many other reasons (especially if you have an arts degree), hold that moment.  Trust your gut.  I get that you’re junior, that that muscle is as yet underdeveloped but it’s in there.  Your answer is in there.  The exams are the beginning of you finding your voice as a physician.  Don’t worry about failing.  This is the safest place to fail.  You wont harm anyone.  You wont have to tell anyone their loved one is dying.  You wont have to say to a patient “I made a mistake…”.  Your pride might get wounded if you do, but I don’t need to tell you that is nothing in the face of a medical error.

When you have that moment when your mind freezes, when you panic, when something screams at you “I don’t know!”, you know what?  It’s okay that you don’t know.  Half the time you really don’t.  Answer C, put a star next to it, move on and calm back to it later.  Or take a time out – stop, close your eyes, take 5 really deep breaths in and out, open your eyes, and keep moving, come back to it later.  The answer might come to you in a little while and if it does, wonderful, if it doesn’t, keep your answer at C.

You can’t harm anyone taking this test.  Your family is safe and unharmed, the people you love are okay.  You are okay.  This is all that matters.  This test is not who you are.  It’s a hurdle, sometimes you clear them, sometimes you crash into them and if you crash, you set it back up and you try again.  And the best part is that this is not a patient.  Even if you’re wrong, you’re not wrong, because you can’t hurt anyone doing this test.  On Monday, start trusting your gut.  It’s an ill-defined thing and it’s scary but ultimately, it’s worth it.

Good luck to all the candidates sitting the FRACP Part 1 Written Exam on Monday!

*patient information heavily de-identified and changed for this piece.

One last time.

I told a man he was dying today.  He wasn’t old.  His life had been written for him by his parents and his circumstances, and as we sat there, in his room, in a nursing home, even though he was too young and too cognitively intact for a nursing home, I watched the sun filtering in the window and I wondered why.

How did I come to be sitting here, and him there?  How had I been born to two parents who in spite of their mistakes, didn’t put me in danger, kept me safe, and warm and fed?  How had he been born into the opposite?  What had happened to his parents?

When I told him, he nodded, announced he was tired, then told me I should have worn more makeup to deliver news like that.  It was no surprise to him.  We both had a chuckle.  His writing had been on the wall for a while, and today, more than he was out of time, he was out of fight.  “No hospital” he told me, when I offered a last-ditch attempt to turn things around, “no more”.  I helped him into bed, he intermittently shouted at me, followed by intermittent sheepish silence.  We talked about palliative care, he signed the form with his wishes, not for transfer to hospital, call his social worker when he died, he wanted a funeral in a big church.

I wanted to hear everything.  I wanted to hear all his stories.  Why his bedroom was decorated the way it was.  Who he’d been.  There was no time.  Earlier in the week when I’d met him, he didn’t know me, he shouted at me for the entire visit.  I tried everything I could to try and turn the ship around, but decades of hard living, multiple diseases all conspiring against us, won against my feeble attempts.  When I discussed him with my consultant, she gently suggested it was his time.  There’s always a part of me that wants to fight and she saw this, she let me try.  When I saw him again today it was on his face and in my heart.

I’ve never told a person they were dying before.  On a normal ward job, by the time they get to you, they’re unable to talk or they’re already gone and you’re having that discussion with devastated family.  Today was a long and private discussion, met by my patient with quiet acceptance, with courage, and with peace, in spite of his young age.  There was a both a stillness and a rawness in our words, he was not the sort you could mince words and I’m not the kind to try.

At the time I was focused on making sure he would be comfortable and not be taken into a hospital system that at his stage, would do more harm than good.  We planned a goodbye party.  The chaplain brought him fruit.  Afterwards the nurse and I got in the car and drove to our next appointment.  And it wasn’t for a long time later that the seriousness, the specialness, and the immense privilege of that discussion hit me.

I feel both sad for my patient and happy to know him if only briefly,  immensely humbled to be a part of his final journey, overawed at his bravery and courage in facing it the way he does.  This is why I did medicine.

Something happens to you in medical school.  You forget about why you did it in the first place, you forget you wanted to help people.  You get stunned by bright lights, start trying for the impressive specialties, ditch the touchy-feely stuff in case people don’t think you’re serious about the scientific side of medicine.  You use all the jargon, no lay terms, you pride yourself on it, you assume that those who prioritise caring over the science of it must be covering for their lack of knowledge.  And then if you come to your senses and return to those values, you wake up inside that dream.  When I was done chasing the bright lights and found Geriatric Medicine, I told one of my bosses from a different specialty what I had chosen.  He pursed his lips and shook his head.  ‘What a waste’ he retorted.  I looked him squarely in the eye and loudly disagreed.  I wanted my resident to hear how wrong he was.

When I left my patient today, I said I’d see him again next week.  “If I’m still alive!” he shouted with the sort of cheer that is half joking and half sad.  He is why I did medicine.  I am humbled and rewarded to be his doctor, even for just a few days of his life.

At the end of the day, our team went through our list of patients.  Someone announced he was now discharged from our service, he’d been referred onto our palliative care colleagues.

“He’s not discharged yet” I said out of nowhere.  It’s my first week in this job by the way.   “I can’t.  Not yet.  I need to see him one more time next week, I need to make sure he’s comfortable”.

There is silence.

“So do I” says one of my nursing colleagues.

“Me too” says another.

We keep him on our list so we can see him just once more, and try to help just one last time.