internship and residency

Hitting Home

My first ever thank-you letter as a doctor came when I was an intern.  It wasn’t for an arm I plastered, or a pneumonia that cleared up with antibiotics, or because I was the pinnacle of kind, wise and caring doctor.  It came from the local police station.

A few weeks into internship, I was doing emergency medicine and freaking out on a daily basis.  I will remember this day forever, if only because there was two patients in the waiting room!  One was a straightforward followup case who just needed checking over, the other came up as ‘alleged assault’.  I’d never come across it in medical school.  We had minimal domestic violence training.  I baulked at the list and went to click on the other, easier patient but the resident on with me beat me to it.  The ‘alleged assault’ patient was mine.

For the next 3 hours (hey, I’d only been an intern for 3 weeks and I’d never been in this situation!) I learned about this woman* who had suffered years of abuse and threats.  She had stayed with this man to protect her children because he’d threatened to kill them if she ever left.  The kids had become teenagers and had convinced her to leave and that they would be okay.  They’d all turned their phones off.  They’d all told their relatives to turn their phones off.  Instead of sitting on their dark secret any longer, they’d involved everyone.  And everyone got on board.

The woman was tiny, and shrunken in her chair.  She couldn’t look at me.  She answered everything in short sentences or single words, her kids prodding her to tell me more.  She was covered in bruises.  I had no idea what I was doing.  I went to my boss whose one piece of advice was “X-ray EVERYTHING” (meaning everywhere that was injured). So I did.  I x-rayed every injury.  I asked her how every single one happened.  I asked her about every time she could remember him being violent.  All the threats.  I dutifully wrote it all down.  I photographed every bruise.

When you’re an intern that doesn’t what they’re doing, it goes one of two ways.  Either you gloss over it and hand it to your boss, or you overthink it, and spend WAY too long going into detail that most of the time isn’t relevant, until your boss comes and fishes you out from the deep.  My boss didn’t in this case, I think because he got it.

The nurses called the police and they showed up.  They came to me and asked me to complete an official statement.  I was mortified.  I’d only been a doctor for 3 weeks and told them so.  They said it didn’t matter, I had the qualification, so I was qualified.  So I told them everything she and her kids had told me.  I printed out all my notes.  All the x-ray reports.  The pictures of the x-rays.  I asked the policewoman how she does her job every day.  She told me that because sometimes, she got to put the bad guys away and that made it worth it.

3 hours later the lady left.  The kids were taking her to a family friends house, hours away, all of their phones still switched off.  A team effort to give this lady an exit into the life she had always deserved.

And I forgot all about it.  I stopped taking hours on my patients.  I saw patients with broken arms and pneumonias and strange surgical problems and women in labour and elderly patients struggling at home and kids with ear infections.

A few months later a letter appeared at work for me.  From the local police station.  In it, on police stationary was “Dear Doctor G, on behalf of local police station, we’d like to thank you for your extensive documentation of Mrs ***’s injuries and histories.  Due to your large contribution to the case, the perpetrator was convicted and received a long jail sentence.  Regards, Constable ***”.

It wasn’t the thankyou letter I’d ever imagined receiving as a doctor.  I always thought it would be some eloquent and flowery prose on what a wonderful impact I’d made on healing and helping Mrs’ So and So from her pneumonia.  And at the time I didn’t know how I felt about it.  Tonight I’m watching the ABC documentary, Hitting Home, with years of experience under my belt, and wondering how that lady is going, and realising the impact of taking someone’s story seriously.

Until the last couple of years, people haven’t taken domestic violence seriously.  They’ve shied away from it, minimised it, pretended it wasn’t that bad.  Distanced themselves, blamed the victim for ‘not leaving’, blamed the victim for ‘provoking’ their partner.  Or failed to recognise that violence isn’t always physical, that abusive and controlling behaviour was somehow normal for ‘that relationship’ where ‘they always fight’.

Women don’t leave these situations because their lives and their kids lives are at risk.  Women get into these relationships with this men because they usually are pretty nice guys to begin with who then begin years of slowly and insidiously escalating their level of control and planned destruction of self-esteem.  The fact that people are still asking why they don’t leave defies belief, especially when they’re not asking why the man is violent.

The biggest thing I’ve learned about domestic violence in the last few years, is that it’s not always physical.  It’s emotional.  It’s financial.  It’s sexual.  It’s stalking.  There’s a very good breakdown of what constitutes abuse here.  And the more we recognise it, recognise that it’s wrong, that as Rosie Batty so rightly put it, recognise that we should be outraged that our fellow humans should be treated with such disrespect, the more awareness that we raise, the harder we can come down on it.  I like to think about the one-punch can kill campaign as an example.  Because of the level of awareness raised about that, the legal system can now argue that given the level of awareness, people who knowingly coward-punch another person now gets much heavier sentences.

We need to achieve this for domestic violence.  We need to talk about it.  And we need to end it.

*This person has been completely de-identified and some details changed to protect her identity.
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How to be a good intern on nightshift.

I am a cranky cranky person on nightshift.  I don’t sleep well during the day (even less now with a baby), I take ages to wake up during the night and my notes can be very thought disordered.  My saving grace is that I care.  Nothing makes me more annoyed than people who show up to work to write notes and tick boxes and order tests and completely forget about the person in the bed.  And since I’m on nightshift and so far it’s been a week of rage and things left unsorted, I thought I’d write this list for the next generation of interns.

How to be a good intern on night/evening/any after hours shift.

  1. If you order a test you chase a test.  If you order a test but your shift finishes prior to its return, you tell the incoming person to chase the test and tell the medical registrar the result.  Always tell the medical registrar the result.  Even when it’s normal.
  2. You do not diagnose anxiety or heartburn on an evening/weekend/night shift.  Ever.  The med reg is allowed, the boss is allowed, you are not allowed.  Ever.  If you suspect heartburn, you have to prove to me it’s not a heart attack.  If you suspect anxiety, and do no blood tests, no chest xray, basically nothing to show me there’s not pneumonia, a pulmonary embolis, a heart attack, or something else bad, you’re in big trouble and not just from me.
  3. You do not prescribe valium, or any other benzodiazepines without checking with the medical registrar first.  Ever.
  4. If you say to me “I don’t know what’s wrong with them but I think they’re sick”, you get a gold star.  Thankyou for having the courage to recognise the limitations of you knowledge, and the clinical judgment to recognise something is wrong.  This is all I need from you.
  5. None of us like doing lumbar punctures.  If you don’t know how to do one or don’t feel comfortable, tell someone.  Don’t try and get out of doing it. The patient needs it.  End of story.
  6. If you say to me “I don’t know what’s wrong with them but I think it’s nothing” or “the patient was admitted with x, but I don’t think they have x” and have no basis for either of these statements other than your own reluctance to collect blood/put in a cannula, then you’re in trouble.  Big trouble.
  7. You don’t need to diagnose anything.  You need to come up with a differential diagnosis in order of most scary disease to least, do the appropriate investigations, and tell me about it.
  8. Tell me if you’re drowning.  Gold star if you recognise you’re drowning.  Double gold star if you ring me up and say “the nurses keep calling me and all this work is piling up but I have so many clinical reviews to do and I’m not going to get to it all”.  I will manage your workload for you if you let me.  If you tell me nothing and I have every ward in the hospital telling me that you’re not answering your page and I ring you up and you tell me you’re fine, again, you’re in big trouble.
  9. “I feel uncomfortable doing this thing you/a boss/some other doctor told me to do and here’s why” = gold star.  Trust your gut.  Don’t let anyone give you shit about it.  Don’t worry about angry doctors – remember why you’re here and ask yourself “what does this patient need and how do I achieve it for them?”
  10. Split up your workload.  When I was an intern I’d do a round when I got to work, then at 1am, then at 5am.  The first round I’d do any outstanding cannulas.  The second I’d do all the morning insulins and drug charts.  The third I’d do any cannulas that popped up during the night that were needed for the morning drugs.  On every ward I would write “Board/book cleared at 0100am, will return at 0500am, please call if anything urgently required”.  That way you wouldn’t get a million phone calls.  Of course things get busy and people get sick and it’s not always that straightforward but if the nurses know you’ve been and are coming back, they feel a lot more confident in your abilities.
  11. As always, your registrar always appreciates chocolate.  Always.

How to be a good intern.

I feel like I’m qualified to make this post now, having run the full gamut of medical interns from so-barely-there-I-don’t-your-name to here-take-my-job-you-awesome-machine.  When I was an intern I really really wanted to be that star intern that was just basically awesome in every domain that everyone raved about.  The only problem was that I had no idea how to achieve it, or really even how to define it.  I was pretty good, sometimes great, but never the full package the perfectionist in me wanted to be.  And Googling it was NOT helpful unless you’re an American intern where you’re actually expected to know stuff.  As an Australian medical intern, you’re expected to do more and know less.  Only you don’t know how to do more because you know less.  It’s a tough year, and I wanted to write my list on how to be a good intern.  As usual, a big chunk of it is tongue-in-cheek and not be taken seriously, but could be, and if you did that would be AWESOME.

How to be a good THE BEST intern.

  1. Your registrar needs coffee whenever you think of coffee.
  2. Don’t bake.  I bake.  I have to bake.  It’s procrastibaketion for exams.  If you bake then what will I do?  You can however, bring coffee.  All the coffee.  You may also bring chocolate.
  3. If you could have my patient list and all the blood & imaging results written out on them and a photocopy for yourself done before I get to work, then you’re a little bit awesome and a little bit frightening in equal measure.
  4. Telling the nurse/NUM/physio/OT/social worker our plan right after we’ve made the plan shoots you to the top of the list for star intern.  Bonus points if I see it.  Full winning points if the boss sees it.
  5. When I come to work and find new patients on our list and you say “yeah I’ve read the plans they wrote down in Emergency and I’ve done the plans” then I will hug you.  And again, full winning points if the boss is there when you say it.
  6. Say “I haven’t done that yet, I’ll get right on it” when I ask if x has been done, rather than “I dunno…”
  7. Your gut instinct is key.  If I or my boss or anyone asks you to do something you don’t feel comfortable with, whether that reason is real or just a lack of knowledge on your part, saying “I don’t feel comfortable” is actually really appreciated.  The swiss cheese model of error lines up when this doesn’t happen.
  8. Be cheerful.  Yes the job stinks some days.  Yes you get asked to do stupid administrative things or call for consults when you think it’s pointless.  There is actually a point I promise.  It takes years to see that point.  If I have to pull out the “if this were your mother…” argument, you are not heading towards a good evaluation.  A friendly attitude is everything and remember, the boss often has 30 years of experience.  You have months.
  9. Hurry me up.  Tell me to go faster.  Tell me to finish the round so I can study.  When the round is done, get my mobile number, kick me out and tell me to go study and call me while I’m studying with any questions you like.  Please don’t ask me to sit next to you to keep you company while you do all your jobs and check everyone’s results.
  10. Did I mention coffee?  Now is a good time for coffee.  Feel free to suggest it.
  11. If the ward clerk loves you then I know you’re good. Ditto the NUM, and the nurse named Dazzle whose been there for 30 years.

And now, as you breathe out.

I read back over this blog today and realised it’s been going since 2010.  The bulk of it was written in internship and residency and it very much reads like someone living their life in between those two years of utter disarray.  And then, two years ago, the snow globe that was my life was shaken and shaken and shaken.  By the time the pieces had settled, so much had happened and the day-to-day vagaries of my job stopped mattering, as I’m sure they do anyway.

It’s hard in medicine to have a blog.  Really really hard.  You have to be so careful.  I still remember Barbados Butterfly who had the best blog about being a woman in surgery until the hospital bloody made her take it down.  There’s so much I want to say about the last two years but just can’t.  All I can say is that 2013 was the worst year of my life.  So bad that I quit the Internet.  Which for long-term readers from the early 2000s is probably inconceivable but it happened.  For all bad events that happen in your life though, things settle eventually and you get to process and box it all up to put on your trophy shelf of Life’s Big Event’s.

The biggest and best thing that has happened for me though is that I had a beautiful baby girl with five fingers and five toes whom I can only describe as being sunlight personified.  To steal a phrase, she is incandescent.  I never thought I would feel that way about anything.  Babies are nothing like what they’re sold to be.  She put everything, absolutely everything into perspective for me and for this I am eternally grateful.

The Internet is weird these days.  Everything is packaged up so you can sell something.  Mummy blogger.  Daddy blogger.  Doctor blogger.  Fitness blogger.  Fake-cancer-survivor blogger.  You’re almost pushed into sieving yourself into one kind of thing and only posting about that.  If you eat healthy you can only post one YOLO meal a week.  Green smoothies compulsory.  Fitness?  God forbid you should post a photo looking like a slob on your couch.  I don’t think I could filter myself even if I wanted to.

I thought about deleting this one and starting again, but then realised that the progression through internship and residency, and then to registrar is probably worth a read.  Even if two years of that registrarship isn’t documented, I can write in retrospect about some things.  So watch this space, and if you were holding your breath, you can breathe out now.