work

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.  💖

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.

That conversation.

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

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

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

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

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

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

 

Reasons why I am late sometimes.

I was on Facebook the other day and watching a bunch of people complain about their doctor being late.  I started wondering about all the things that made me late to see patients so I thought I’d write them down in the hope it would make everyone in the SMH comments section hate doctors a bit less.  Possibly more if they see this but hopefully not

Reasons why doctors I am late sometimes.

  1.  I have lots and lots of patients.  This one seems obvious but in a hospital you can never see a new patient quickly.  It comes back to bite you if you do.  And most of the patients in hospital are of an older vintage and can’t be expected to remember the bits of their medical history I want them to remember so I have to ring their GP, their other hospitals, and their kids and their neighbours to piece together enough of a history that helps me understand why they’ve come to the emergency department unconscious, and what of their medical history is likely to slow them down getting home.
  2. Figuring out what medication my patients are on.  I know this should be in 1 but it deserves it’s whole own category.  Working this out is a bit like India Jones with those Roman numerals in The Last Crusade sometimes.  The amount of medications that some people are on and who has changed them and when is mind boggling.
  3. I am hiding in the toilet from the boss that was really mean to me a year ago and I don’t want him to see me and be mean to me again and I have to text my intern and find out if he’s gone even though he probably has no idea who I am but he might.
  4. I need a coffee and have in fact slowed to a standstill while my panicked intern runs downstairs and comes back and puts a coffee in my hand so I can drink it and we can keep moving.  Also I’m not allowed to drink my coffee on the ward/in front of you so I have to finish it before I keep moving or hide it in convenient places where it can’t hurt anyone.
  5. I am eating lunch.  We get half an hour for lunch.  I take 9 minutes exactly with an extra 2 minutes staring into space/groaning about having to stand up again.  It still counts as a delay because I could be seeing patients in that time.
  6. I already came to see you but you were asleep/getting a test/told me to piss off.  I always come back!
  7. I am chasing a delirious person.  This a common and unseen job of hospital doctors/nurses/cleaners/security/random hallway guy.  Delirious people have no idea where they are or how they got there so it’s only natural they would try to leave, and only natural they would get very upset, nay violent, when it is suggested to them that they can’t leave.  Chasing a delirious person means walking after them, but not too close, trying to join them in whatever delirious place they’re in and trying to reason with them into returning to that strange bed with the strange other people in the other 3 beds in the room because it’s good for their health.  No, I wouldn’t believe me either.
  8. Ranting at the ward clerk because my patient keeps calling me nurse.  I have been seeing them daily, every day, for two weeks and introducing myself as their doctor and it. does. not. compute.  So then I inevitably rant at the sympathetic ward clerk about #everydaysexism before my intern comes out and tells me the orthopaedic surgeon is here to have a chat about our patient and ask which guy he is in the group over there.  Naturally, it’s a woman.  This rant always makes me late but it needs to be had.
  9. I am hungry and my blood sugar is -5 and there are no patient biscuits in the cupboard so I have to go upstairs to the vending machine and eat something delicious but disgusting so I can make the words English good.
  10. I am blogging.  Haha just kidding, I wish.  Hospitals have the strictest firewalls ever.  They even block reputable medical websites.  But curiously not Youtube.

And while I’m procrastinating…

Did I really not post since last September? Let me catch you up on the last year:

  • I started physician training.  (For those not familiar with the system, when you finish your internship and residency, you often then thinking about the pathway you want to do: surgery/physician training/obstetrics/general practice/anaesthetics and so on.  Physician training is what you do to become a medical specialist something, don’t ask me what yet!)
  • I spent six months at The Regional Hospital From Hell.  It wasn’t all that bad, but it was really really hard.  Like, you pick up the phone 24 hours a day for 7 days a week, every three weeks, for four hospitals spanning a large country region.  And you deal with questions like, chopper or ambulance?  And you keep your cool when people call you at 3am for a medical issue not even remotely related to your specialty because they don’t want to wake up the right person who is known to not keep their cool and figure since you’re so junior, you’ll just say yes.  You come into work for all seven of those days too.  The sleep deprivation was a bitch.  As was seeing my husband once a week (when I wasn’t on call).
  • Lots of my hair fell out from the stress and I discovered a bald patch! I have the best hairdresser ever though, and it all grew back.
  • I made some new friends in my new network, and started working at my new home hospital which is great! I found a lovely study group…now to just err, study (more).
  • I stopped being vegan because it was too hard, I realised that the population examined in Forks Over Knives (i.e. I’m not an overweight type 2 diabetic who required bypass surgery) and there’s some great evidence for The Mediterranean Diet.  So rather than treat myself for something I don’t have, I switched over to preventing something that I may easily develop.

In short, life has been boring for a blog, but exciting for me.  Interesting election huh?  I wasn’t surprised by Tony Abbott winning it, and I got a sausage AND a cake at my local voting station.  What have you been up to?

Conversations in strange places

It’s 7pm. I’ve hung around at work well past finishing because I have a dinner date nearby and I’ve just finished up in critical care. My friend whose on until 11pm and I are sitting at the nurses station talking about life and science fiction, future plans. In the background monitors are alarming, sounds I hear as I fall asleep at night now, ringing in my ears, reminding me that medicine never sleeps.

My friend is brilliant. So keen is he to become an ICU specialist, that he has taken responsibilities far beyond the rest of us, and been rewarded with skills and knowledge that far outstrip my own. He’s waxing lyrical about laterally thinking your way through a nosebleed in a bleeder (a sick patient prone to bleeding too much), I’m having one my regular crises of confidence, the uncomfortable result of being part of a specific minority in med school that all too slowly is disappearing Right in the middle of my crisis of future failures he lands it on me.

‘Make your worst performance the best on the day’. My fugue is broken – and he explains that as the result of being forced to do high-level music for his entire life (that he says is specific to his cultural heritage), he had to take nerve racking performance exams yearly. For his whole life. That he met with prospective failure, and sometimes the reality, so often that he learned this valuable lesson. His father explained that the more you practice, the more our bring up your own worst performance, that if on the day you choke, you drown in anxiety, that even if you give your worst performance, it will be the best performance for the day.

It was one of those moments in life where you feel your mind undergo a massive correction, that ‘aha! I understand what I need to do now!’ moment. Where self doubt evaporates and is replaced with motivation and interest. Your baggage can cloud a lot for you.

In the background, a new patient is wheeled in, intubated, an unfortunate survivor of a horrific accident. More alarms. One of the nurses asks another if they want Chinese takeaway for dinner. One of the seniors wanders past and reminds my friend that a new patient has arrived, does he want to put in some lines?

We say our goodbyes, I thank him, and as he walks away he says, ‘us good people have to stick together you know’.

I swell up with pride to be counted among his own.