The Medicine

by Karen Hitchcock

  ALSO BY KAREN HITCHCOCK

  Little White Slips

  Dear Life

  Published by Black Inc.,

  an imprint of Schwartz Books Pty Ltd

  Level 1, 221 Drummond Street

  Carlton VIC 3053, Australia

  enquiries@blackincbooks.com

  www.blackincbooks.com

  Copyright © Karen Hitchcock 2020

  The essays in this collection were published in The Monthly between June 2012 and October 2018. Karen Hitchcock asserts her right to be known as the author of this work.

  ALL RIGHTS RESERVED.

  No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form by any means electronic, mechanical, photocopying, recording or otherwise without the prior consent of the publishers.

  9781760641931 (paperback)

  9781743821275 (ebook)

  Cover design by Regine Abos

  Text design and typesetting by Dennis Grauel

  Front cover images: magnolias: Swisty 242 / Shutterstock; syringe: Laborant / Shutterstock; grainy background: Panadin12 / Shutterstock. Back cover images: flower: Sandra M / Shutterstock; human body map: Hein Nouwens / Shutterstock. Part title illustrations: Plawarn / Shutterstock.

  For Ida and Yvonne, my “lit” daughters

  And for Dr Michael Oldmeadow, rockstar

  Contents

  Introduction

  DOCTOR AT HOME

  When the Doctor Needs a Doctor

  Please, Go On

  Ironman and Medical Exams

  The Gentlemen’s Club

  A Case of Rust

  AGED CARE

  A Visit to the Nursing Home

  Thinking Again about Palliative Care

  The Dementia Cure

  PILLS, PILLS, PILLS

  Big Pharma

  The Pill Problem

  The Trouble with Miracle Cures

  Crazy Pills

  Too Many Pills

  FOOD AND HEALTH

  The War on Food

  The Next Big Thin

  Fat City

  “Fat City” Revisited

  OTHER APPETITES

  Precious Sleep

  A Former Smoker’s Lament

  A Fine Line

  Sex and Pharmaceuticals

  High Times

  Drugs: On Medication, Legalisation and Pleasure

  THE BODY AND THE MIND

  In the Body and in the Mind

  Medicine and the Mind–Body Problem

  The Art of the Body

  Sick Day

  DOCTOR ON THE WARD

  Performance Check-up

  Do No Harm

  The Student Lottery

  The Rural Doctor Problem

  Working Regional

  Ill Communication

  The Eyes Have It

  Love, Fear and Hierarchy

  What the Hell Was I Afraid Of?

  The Biggest Decisions

  ETHICS

  Doing the Right Thing

  The Right to Die or the Right to Kill?

  Germ Welfare

  A Bad Case of the Flu

  THE SYSTEM

  Preparations for the Storm

  Society’s Safety Net

  A Pain in the Tooth

  Looking for Trouble

  Mind the Gaps

  Health Care, American Style

  Medicine’s Mission to Mars

  Last Resort

  Some Days

  Acknowledgements

  Introduction

  When I was a full-time doctor in a busy city hospital, I’d cycle to work every day wearing black pants, a silk shirt and jacket. The uniform didn’t vary as there were no seasons inside, nothing circadian. The temperature and lighting sat at a cool white all year round. When I’d walk through the smooth sliding doors into the refrigerated air, the world outside ceased to exist. The hospital was a closed, complete ecosystem: food, showers and beds, companionship and drama. I could have lived there. It would have been more time-efficient. For when I left to go home I took the place with me: sick patients, departmental politics, unfinished clinic letters, roster disputes, a never-ending list of tasks and questions and key performance indicators. Bed shortages, shrinking budgets, clinicians juggling patients’ needs with those of the institution. I squashed my family and friends into gaps. I mentioned to my boss in some after-hours meeting that my daughters were home alone. He laughed and sing-songed, “Uber Eats again!” No need to wonder why, in the entire time I worked there, I was the only female full-timer in what was one of the biggest departments in the hospital.

  These columns and essays were written in the early hours of the morning, before the trams in the street beyond my window started rolling, before anyone was awake. This was the outside space from which I got the chance to think quietly about what it was we were doing in all that hospital-hectic, which could induce a kind of white noise on the brain.

  The Japanese have a word – shrinin-yoku – that roughly translates to “forest bathing”. You go outside, walk through some trees and just breathe. Doctors in Japan prescribe it for mental health and wellbeing. Observational studies and randomised controlled trials have validated the idea: we wilt when our eyes are starved of green. First I quit the hospital and went freelance. Then last year I moved from the middle of the Melbourne CBD into a house in the bush in the mountains, with plenty of water, an orchard and a vegetable garden. Full-time forest bathing. When I’d panic that I’d totally fucked up my life, I’d walk outside, grab my pick and shovel and plant some trees. By the end of autumn I’d sunk hundreds of maples and almonds and oaks. It’s a giant feat of optimism to plant a twig and trust it into maturity. It changes your sense of time. Helps you catch your breath. I read apocalyptic novels, watch dystopian television and think: I’d better plant more perennial vegetables. Who knows how crazy shit’s going to get. I listen to music and stare out the window, or sit on the grass and watch the seasons strip bare then dress the gardens, listening to the symphony of birds and insects. I dream and I think for long stretches of time.

  I now work in my own small inner-city clinic a few days a week, practising slow medicine, mainly prescribing medicinal cannabis to patients who suffer pain, anxiety, insomnia or are dying. I see my patients in a small cream-walled room in an ancient mansion on a hill. It is quiet. I do not have a boss. I go at my own pace, at the pace my patients need. There is never a cannabis emergency. I make school lunches, attend school concerts. When my daughters want to talk to me, I don’t have to smother twenty competing demands on my attention. I turn towards them, sit down and listen. I cook. We eat together. It’s their turn. I pull on my overalls and sink my hands into the soil, and the memory of myself in the hospital is of a hyperventilating girl playing dress-ups. But I have written proof that I was able to preserve small pockets of time to think.

  When the Doctor Needs a Doctor

  Early Friday morning, I got cancer. Bad cancer, the kind that can colonise your bones. Mine had spread to one bone in particular: a rib in the middle of my chest. To diagnose myself I took a history, questioned myself about the nature of the pain and did a physical examination. The pain woke me up, it was grinding and rated seven out of ten when I moved or breathed. There was “point tenderness” over my fourth rib just medial to the mid-clavicular line, and crepitus (a distinctive crackling feeling when shards of bone grind together). The invaded bone curved right over my heart’s left ventricle. A terrible click vibrated through my chest whenever I took a breath. Given that I hadn’t fallen from a ladder, I knew this was a “pathological fracture”: one caused by something bad happening inside your body, such as spreading cancer. I lay down on the lounge room floor, staring at the ceiling, wondering if it was a bre
ast or lung primary, and how many months I had left. Then I called my workmate Harry.

  I’ve had a lot of diseases over the years – Hashimoto’s thyroiditis, hepatitis, a ruptured spleen and multiple episodes of lymphoma – with peak incidences around the time of my final med-school exams and then, six years later, the specialist exams. There are millions of diseases, and a body can generate a kaleidoscope of sensations: who’s to know for certain if the pain in your gut is the result of too much hummus and not actually a huge tumour in your pancreas? Who can know for certain without having a long, hard look at your internals with a high-resolution scanner?

  There’s talk in the media and around the wards about “over-investigation”. That is, looking for a disease that is highly unlikely to be present. Take lower back pain, for instance. Each year Australia spends about 220 million Medicare dollars on X-rays, CT and MRI scans for lower back pain. Most people experience back pain at some point in their life, which makes back pain “normal”. Though normal, pain makes us anxious: we want to know why we are feeling it, if it is a sign of something dangerous, something that may leave us permanently incapacitated. After all, every nerve that allows you to move and feel your body travels through the spine; what if one of the bones has moved and compressed a nerve? So you go to the doctor, who engages you in a strange dance: she raises your leg, asks you to bend it, presses and pulls, taps your knees and ankles, bounces a pin across your skin. “All good,” she says. “Heat packs and paracetamol, and don’t take to your bed,” she says. Your heart thumps. You had pictured severed nerves, surgical interventions; your future in a wheelchair. And in the face of all this she asks you to trust her tendon hammer?

  There are clear international guidelines outlining the limited circumstances in which it is appropriate to scan a patient with back pain. If we followed these guidelines we’d spend only a fraction of that $220 million. But we don’t. Health economists, researchers and politicians wag their fingers, cry waste, and then chuck their reports in the air. Why won’t we listen?

  “But,” you say to your doctor, “what if …?” Anxiety courses from your eyes into hers, which for a microsecond display the tiniest flicker of uncertainty. You grasp your flank. Maybe you feel your left foot tingling. She looks from your right eye to your left to your right, wondering if she trusts her tendon hammer, remembering that one case that one time. The most powerful anxiety-relieving item on the market is not Xanax. The most powerful anxiety-relieving item available is a high-tech scan.

  I open a detailed illustration of chest anatomy on Google to check that I haven’t neglected any possible sites of disease, while Harry and I consider the differential diagnoses over the phone. We come up with a fractured bone or a separation of the cartilage and rib.

  “You probably did it rowing,” he says.

  “How do you know?”

  “Because you row.”

  As I’ve advised dozens of patients over the years, if you break or dislodge a rib there is nothing to be done except swallow painkillers, apply ice packs, and not row, swim, run or lift heavy objects until the bones re-knit. I reassure myself, and follow my own advice, for a day. Then I order an MRI.

  In my defence, the scan is – quite rightly – not covered by Medicare, so I pay for it in cash. As punishment for over-investigating myself, the tech makes me lie rib-down on the scanner bed for the entire thirty minutes.

  A magnetic resonance scanner is a gigantic humming electromagnet that spins and excites all of the hydrogen nuclei in your body. Then it lets them relax, and turns this into images. The magnets generate sounds much like a painfully loud industrial experimental garage band. Unlike X-rays and CT scans, there is no ionising radiation exposure involved in MRI. You’re just bathing in an incredibly powerful electromagnetic field, having your atoms manipulated for half an hour.

  The problem with increasingly sophisticated medical investigations is that they sit in their expensive suites like coin-operated gurus. We know they’re in there and they can tell us the answer to everything, even the things we already know, don’t need to know or would be better off not knowing. So it’s helpful to be able to tell a patient that I don’t think they need a test, and neither does Medicare. It’s like trumping an argument with “Because Mum says so”. Some patients, however, stubbornly resist their doctor’s reassurance.

  I get dressed and go backstage, where the radiologist sits in front of a bank of screens, searching for anatomical anomalies. He shakes my hand and then points his mouse to the aberrant gap between my fourth rib and its cartilage. Despite the fact that I’d made no mention of cancer on the request form, he smiles and says, knowingly, “Rest assured, there’s no sign of any underlying mass.”

  Please, Go On

  The minute I was accepted into medical school I became, in the eyes of my friends and family, a professor of every clinical specialty, with a sideline in veterinary medicine. The calls started almost immediately. Overnight, I transformed into that respected (if occasionally lethal) person in the medieval village who had no training but was somehow the one everybody went to for treatment and counsel. I had a new authority I hadn’t earned, didn’t want and (despite anxious protestation) couldn’t negate.

  After I graduated it became trickier to cry complete ignorance. Saying I didn’t know turned me into an object of contempt. It’s difficult to know and harder to be right about a clinical scenario related by email. A few years ago a particularly hypochondriacal family member (who only calls when she has a medical concern, usually a single episode of diarrhoea) thought she’d broken her little toe. Terrified, she told me the story and symptoms. I said it probably wasn’t broken, but even if it was she wouldn’t score a cast, and that she should just be gentle with it and it’d get better by itself. She sounded doubtful. I reassured her. Her doubt escalated. “Well, if you’re worried,” I said, “maybe go see your doctor?” Later that day I received an SMS – no words, just a photo – of an X-ray of her foot with a big red arrow pointing to a tiny cracked bone. I could feel it so sharply, her contempt.

  When my siblings had children, my task was to advise – from interstate, over the phone – about the need or not for their infant to be hospitalised. I’d listen to long, rambling stories about mucus and vomit and what might be a rash and someone they knew who knew someone whose kid was just like this and was reassured by their doctor and the kid ended up in intensive care, almost dead. For a very junior doctor who’d never laid eyes on a sick child, these calls were a source of great distress. I’d listen, my mind screaming unspeakable words, words like meningococcal meningitis, acute lymphoblastic leukaemia and osteosarcoma. I’d say, “Does he have a fever?” They’d say, “Hold on,” and come back and tell me his forehead felt hot. Everyone’s forehead feels hot. Everyone’s throat looks red. How else would we score days off school? I bought electronic thermometers for all my family members and told them not to call me without a readout. I completely understood their impulse to call me and probably would’ve done the same. I do do the same, to my friend Mike, a very experienced physician in his late sixties. In the past few months he’s talked me down from a self-diagnosis of imminent diabetes (because I found a tiny skin tag) and melanoma (that was a blood blister), and he stopped me getting an MRI for my achy, post-workout knee.

  If you’re planning on having a doctor in the family, I recommend a general practitioner. One of their greatest skills is the ability to triage the mournful from the sick. And the sick from the sick-sick. Without a full set of obs, a battery of blood tests and an X-ray or two, hospital doctors like me aren’t very good at that, especially not early in our careers. Picking the sick from the sick-sick is the most useful talent a family-member-doctor around the dinner table or on the end of a phone can have. Quiet, febrile, floppy and anuric (not passing urine) is emergency-department bad. Screaming and snotty is probably a-trial-of-paracetamol bad.

  I know that these phone calls and corridor consults are not recommended practice. And I suppose that techni
cally my every response should be “Go see the GP”, but rules and recommendations often get bent and broken for good reason. My brother, for instance, lives on a farm a few hours’ drive from after-hours services and has a son prone to asthma. Advising him and his family to drive to the city and wait half the night in the busy emergency department each time he called would be an outright abandonment of my sisterly duty. I know him. I know the kid. He finds running it all by me to be helpful.

  Unlike my family, my friends and acquaintances always apologise profusely before they ask me anything medical. And afterwards they are grateful to a degree I never deserve. Sometimes they just need to know what kind of doctor they should call, what the word on the street is about orthopaedic surgeon Mr Such-and-Such, whether wanting a second opinion sounds neurotic, if I know a good geriatrician north of the river. I’m usually of no material help at all. I’ve faxed the occasional referral, written a script or two. It is the very rare occasion where my knowledge, connections and my friends’ needs align.

  Strangers mention their aches, pains and troubles obliquely, or in tiny flickers, all the time. They’d quite like to tell a sympathetic ear, and I can’t help myself, I love it. Yesterday the supermarket cashier had sore and poorly healing teeth with CPAP mask complications, the elderly man next to me in the queue at the post office had a sick wife (long story) and catastrophic house fire (longer story), my daughter called me from camp with a headache (pressure from the snorkel mask she’d had on all day), and her best friend needed advice about dressing her cut foot. A medical degree doesn’t confer authority so much as dissolve the line between a polite story and what my daughters would call “TMI”. Get a medical degree and nothing is ever again Too Much Information. The apologies are unnecessary. None of it is onerous or burdensome: to listen, even without all the answers. I invite it – often quite literally. It’s the position I’ve adopted, how I feel part of the world. I’ve been insatiably curious about sentience since childhood, but now my “Please, go on” face isn’t weird and creepy and strangely over-freckled; it’s something approaching trustworthy. Doctorly, if you will.