The Medicine

by Karen Hitchcock

  Ironman and Medical Exams

  Around Australia the registrars are about to sit part one of the medical specialist exams, the rigour of which makes medical-school exams seem like hopscotch. I feel sorry for them: five years on the wards and now trapped inside cages of heart-thumping ignorance. Physicians in their eighties still have nightmares where they’re forced to repeat the exams. I sat them in 2008 and sacrificed a year to that relentless act of endurance. I stuffed myself so full of facts that eating made me sick. I listened to recordings of the review lectures as I drove to work, as I jogged and showered. I sat with summaries in front of my face while my family played; I littered the house with Post-it notes that described pathways and diagnostic criteria. For a year I didn’t glance at a newspaper or a novel or a movie. Like an obsessive-compulsive loop, my every thought ended with the same punctuation: Must study. When it was all over, my reams of notes packed in cardboard boxes, I walked through air without gravity, each thought now ending in a cliff dive.

  After the exams I had to choose a sub-specialty and train for a further three years. Unsure of what I wanted to do, I took a last-minute advanced-training post in nuclear medicine. I was plucked from hectic inpatient wards and dropped into a sleepy office where I rarely saw a patient in the flesh, except to tattoo the skin above their sentinel lymph node moments before the surgeons hacked out a tumour. Mostly I sat behind the boss’s shoulder, trying to decipher ghostly scans. All those years of study, of smacking up against the raw humanity of the desperately ill, so I could sit in a padded chair in a dark room.

  We interpreted images of limbs and lungs and entire bodies riddled with black spots – cancer, infection, broken bones – using rote phrases. In the tearoom, the technicians who operated the scanners talked about something called ironman, an event where they voluntarily paid big money to swim 3.8 kilometres, then cycle 180 kilometres and then run a full marathon (42 kilometres). “Why?” I asked them. “Why?” They shrugged, lifting salad sandwiches to their mouths, tight biceps flexing beneath polyester uniforms, chewing with cut jaws. They talked training hours, diet, drills, PBs (personal bests) and squads. My legs started to twitch. One second I was thinking they were a bunch of monomaniacal psychos with rather pretty bodies, the next I was buying a waterproof, heart rate–monitoring GPS wristwatch. I got a coach. He wrote me a training program that read like a job – two sessions a day, twenty-two hours a week – and I felt a deep relief.

  I’d rise at 5 a.m., drive to the Olympic pool and join my squad. In the fast lane were the semi-pros and the coaches, guys with tattoos of the Southern Cross and the ironman symbol, cutting through the water like sharks. I swam with skinny boys, tough girls and a 65-year-old woman who once finished an ironman event with her foot dangling from her ankle like a flag. She’d severed a tendon at kilometre 22 of the run. “It didn’t hurt,” she told me. “Only the partial tears hurt.”

  After work I’d go to sprint and hill training, or on long solo runs. I bought an Italian bike, light as a bag of flour. I rode with a peloton of men until I grew tired of their chitchat and went out by myself, riding for hours along the fine line that divides effort and pain, my cleats clipped into titanium pedals, trucks beside my elbow, thinking of nothing except how far I’d come, how far I still had to go.

  In the squads I was no one; I came from nowhere. People who didn’t know my last name or my job knew I was gaining on them by the character of my footfall, could recognise me by the colour of my bike. We were a strange sort of community, linked by what we were forcing our bodies to do. You didn’t have to be fast; you just had to keep going. I spent my spare time adding up hours trained, kilometres covered, grams of protein consumed. I studied textbooks of exercise physiology and triathlon magazines. The techs and I DEXA-scanned our bodies to learn the precise percentage of muscle and fat we carried. We diagnosed each other’s kaleidoscopic aches and injuries. I tried to calculate the physiological age of my 35-year-old heart: I pushed myself to my maximum (196 beats per minute) and ended up facedown in the grass, misbeats racking my chest. You can mine a lot of data from your body when you’ve got nothing else to study.

  I raced a half ironman alongside Tony Abbott and beat him by an hour. I raced the Australian long-course triathlon and qualified for the amateur worlds. I’d have to train harder, but I’d get my own racing suit with a golden “Hitchcock” printed across the green arse. I was right in there, wet and steaming and laughing along with all the other biceps and quadriceps, the wetsuited, kickboarding swimmers, the aerodynamic riders and the high-tech runners. And then one morning I stood at the edge of the pool and felt a sick sort of shock: I stared at those people – my squad – and they seemed in that moment a collection of exotic, curious and utterly anonymous creatures in an aquarium.

  I quit the squad and my job and started training as an acute and general medicine specialist. Ironman had been nothing more than an elaborate, frankly exhausting way of moving from the exams back into life.

  The Gentlemen’s Club

  Every hospital has a “residents’ room”. A place only the junior doctors can enter, where posture and politeness are discarded, naps are stolen, bosses are demolished, hook-ups are arranged and black humour reigns. It’s like a pub without alcohol.

  I transitioned from trainee to boss in the same hospital. Overnight, I was barred from the residents’ room and granted entry to the “consultants’ room”. I called it “the gentlemen’s club”. It had chesterfields, old portraits, a cupboard full of (unopened) top-shelf liquor. I’d go there to open my mail. It was mostly deserted – just the odd professor or two sitting at opposite ends – but somehow the toilet seat was always up. And though I’ve never been one to engage in the toilet seat wars – he puts it up, I put it down, seems fair to me – for some reason I started to read this one as a “fuck you”.

  Female medical trainees now outnumber male ones. Behind closed doors this is bemoaned as a “feminisation” of the medical workforce. A phenomenon that will lead to decreased productivity due to all that child rearing. To less doctoring per medical degree.

  I’ve had countless corridor conversations with female registrars – pre-exam and post, partnered and not – about the best time to have children. They approach me nervously, look around to check no one’s in earshot. When did I do it? How? I fell pregnant with twins in my second year on the wards. I planned to take eight weeks’ maternity leave, and come back as a registrar to start the six years of specialist training. The huge regional hospital I worked in was enormously supportive of me as my belly swelled, slotting me into the less acute units such as geriatric rehabilitation. After the birth they extended my maternity leave, then let me job-share with another kid-wrangling registrar. They saw no problem with me running out to the emergency department’s drop-off zone every four hours to breastfeed in the passenger seat of my partner’s car. This kind of flexibility only exists in places battling a workforce shortage. If there’s a line of equally qualified people snaking out the door, who’d negotiate? I know a doctor who received a phone call on the eve of her specialty interview, telling her not to bother because she was pregnant. Outrageous. But imagine you’re hiring a trainee for a twelve-month position. The job is arduous. The more work they do, the further into the year they progress, the better they get, and the less you worry about your patients.

  There are exceptions, but most heads of departments are men getting on in their years. They are married to women who raised the children and kept the home. This arrangement remains quite common among the younger male hospital specialists, and brings with it a particular kind of ease: last-minute after-hours meetings and early start times – things that put me into hypertensive crises – won’t orphan their children. And yet, at least five times, I’ve heard male doctors joke that their wives won’t let them retire: I’d drive her crazy. I’d get under her feet. I’d leave crumbs on her benchtops.

  Periodically, the various specialty colleges form committees to address structural sexism
: the lack of flexibility in work hours, the discrimination against the pregnant. The committees peter out or draft idealistic recommendations using words like “urgent” and “imperative”. But it’s all a show. What department would choose complication and distraction over insouciant dedication?

  We could change structures in the hospital to make it more family-friendly. Have the wards crank up after school drop-off rather than at 8 a.m. Mandate that a decent proportion of the training positions are part-time. Offer paternity leave. In-house child care. Perhaps then there’d be a few more women running the place.

  When I job-shared I had half the week on, half the week off. I never really felt on top of things, or that I knew the patients as well as I might have were I there every day. But no doctor is in the hospital 24/7, and we always work as part of a very large team. Any exchange of information is imperfect. Details will always be forgotten or misunderstood. (Why is that relative angry? Why was the beta-blocker ceased? Has a pulmonary embolism been excluded?) The truth is that no trainee ever feels entirely “on top of things”, so it was invaluable (and comforting) to be able to call my other half.

  I tell the anxious registrars who wonder if they can have a family to imagine the kind of life they want. Public hospitals can be exciting, raw and rich. So can families. There are areas that comfortably accommodate shiftwork: general practice, emergency medicine, anaesthetics. But I feel sorry for the trainee medical specialists. They’ve chosen a medical career where the most intense period of training perfectly coincides with the time to have children. I veer back and forth between “It’s unfair” and “Toughen up”. They’re far more privileged than the woman working three casual unskilled jobs when her period fails to arrive. Perhaps Western, highly educated, professional women can’t have everything. Perhaps no one can. It seems to me that those bloke-jokes – the-wife-won’t-let-me-retire – belie their own sort of sacrifice.

  Count your lucky stars, as my grandmother used to say. The toilet seat might piss me off, but I chose this club, one built over centuries around a gentleman’s schedule. Would I choose it again? I think often of a moment: I’ve just finished the last of my specialist exams after a year of relentless study and work. I’m buckling my three-year-olds into their car seats to take them to the beach. One of my daughters is looking into my eyes with that piercing inquisition young children have not yet learned to suppress. She cocks her head ever so slightly, and there’s neither question nor accusation in her diagnosis: “Mummy. You don’t play.”

  A Case of Rust

  The Melbourne International Flower and Garden Show packs the Royal Exhibition Building and its gardens every autumn. If you try to ride your bike along the shared walkway beside the park, you can smell the lilies as you plough through busloads of retirees waiting to re-board the coaches home. Traffic around the park is in gridlock day and night. Winnebagos clog the side streets. I usually keep to the other side of the street, hoping to ignore the wild crush of people clutching pot plants and Better Homes and Gardens showbags. But then my mother told me she’d entered the hanging-basket competition and asked me when I planned to see her basket in situ.

  My mother still lives deep in the western suburbs of Melbourne, in the same house in Deer Park that I grew up in. In the ’70s and ’80s the houses in our street had elaborate front gardens. The stand-out displays were the giant Mexican cactus garden with a ground cover of smooth white stones, owned by a Polish family; the psychedelic flower garden with chrysanthemums the size of your face, cultivated by an old lady named Pat; the productive Italian garden with row after row of staked tomatoes, eggplants and beans, and not a blade of grass. We had a lawn-and-tree ensemble, which was considered respectable enough as long as the lawn was thick and kept well trimmed. The streets were crawling with kids. We stole the white stones, Pat’s flowers, the beans – mostly to chuck at each other.

  Deer Park looks different these days. There are no kids. Walk down the street on a weekday and you would be lucky to bump into a single person. In my mother’s street the cacti and veggies have gone and there’s hardly any green lawn. Pat’s garden was concreted after she died. More than one front yard is home to a rusting car shell. The drought hit Deer Park hard.

  When my mother retired she took up gardening. She’d read that gardening helps prevent Alzheimer’s dementia; as all the women in our family are genetically destined to spend the last decade of life being fed mashed food through mute and vacant grins, she took sharp note. She bought books about landscaping, did a diploma, joined garden clubs and horticultural societies. For her, plants now have multisyllabic double-pronged names, like aristocrats. She has gardened every centimetre of dirt on her quarter-acre block. You can barely see the roof, the fence, the driveway – the place is a plant explosion. She has even gardened the nature strip, despite the hose not reaching that far; it looks like a museum display entitled “Native Grasses and Shrubs of South-east Victoria”.

  Keeping all this plant life alive during the drought was difficult. The greywater generated by a single retiree is not oceanic, but she did her best: extra baths, washing her sheets more than was entirely necessary, occasionally mixing up the official watering day, buying a tank, and telling herself the reason her water consumption was so high was that we were always so thirsty when we came to visit.

  My mother worked on her basket for a year. She bought ninety dollars’ worth of natives with really long names, put them in the official Royal Horticultural Society of Victoria hanging-basket competition pot, and then did whatever you do to hanging baskets: water them constantly, spin them exactly 90 degrees every few days so the sun hits all sides evenly, trim them, fertilise them, pick out dead leaves, reconfigure plant placement. If I didn’t go and see it she never would’ve forgiven me.

  I bought my ticket online and walked down to the park. The scene inside the boom gates was horrific; all of outer Melbourne appeared to be there. I headed directly for the hanging-basket exhibition – over 200 hanging baskets, arranged in row upon row. On first inspection they were indistinguishable: plants in baskets with name tags, some with prize ribbons. I found my mother’s in a back corner. The leaves of one of her plants were covered in big brown splotches. Her pot was not graced with a ribbon. I walked down the aisles. There were prizes for different categories: innovative, colour, texture, edible, native. The winner of “edible” was a fountain of parsley so green it hurt my eyes. The winning “innovative” basket was a solid ball of succulents turned into a functioning clock face. I had a chat with Pamela, whose basket – a cascade of pink and faded-parchment-coloured petunias coupled with a downy-leafed herb – took out “texture”. “I was actually going for ‘colour’,” she told me, “but I’m pleased with ‘texture’.” She fondled a leaf. “Bugger of a thing to get here, though. Divorce material. I had to rest it on three pillows.”

  An attendant introduced me to the Royal Horticultural Society of Victoria’s secretary, who runs the organisation from her lounge room in Bacchus Marsh. She told me there were four judges, all from “the AHJA”. I looked at her blankly. “The Australian Horticultural Judges Association,” she explained. “It’s a two-year course. But I’m thinking of getting a celebrity to judge next year because we don’t get much publicity. Not compared with the hoo-ha out there.” She flicked her tapered fingernails towards the garden pavilions. “But this exhibition is about ordinary backyard gardeners. We’re not trying to sell anything.”

  I mentioned that I knew one of the entrants and asked if she would comment on the basket. She looked at my mother’s basket, rubbed one of the leaves. “Not a bad basket, but it’s diseased; it’s got rust. We didn’t look further than that.”

  I couldn’t understand it; surely my mother wouldn’t have entered a diseased plant. Maybe that variety of native was supposed to have rust?

  There was a people’s choice award yet to be drawn from a barrel guarded by a volunteer. I voted for my mother’s basket over and over, making up names, changing my handwriting,
until the barrel guard glared at me.

  The day after the show finished, my mother dropped by on her way to collect her basket. She was disappointed she hadn’t won a prize. I told her I’d had a chat with one of the judges. She went very still.

  “They said that it had a little spot of rust.”

  “What? It was perfect when I entered it.”

  “It must have caught it from another basket,” I said. “I didn’t notice. I thought it was innovative, with good texture and colour, and it was far more restrained than the other entries. I loved it.”

  She walked to the Exhibition Building to collect her basket. The security guard told her they were all gone. She didn’t believe him; they argued; he let her in to have a look. She came back to my place empty-handed and rang the secretary of the horticultural society.

  “It’s too late,” the secretary told her.

  “What do you mean it’s too late?” my mother asked.

  “My husband and I organise 90 per cent of this competition. I was too tired to hang around for another day, waiting for people to pick up their baskets. They’ve been distributed to nursing homes.”

  My mum looked shocked. She hung up. “My basket’s been sent to a nursing home.” We stared at each other for a second, mouths agape, then started laughing.

  A Visit to the Nursing Home

  The first time I see Irena, we are two doctors down and have a full waiting room. I call her name, four times. Finally she stands up: ninety-four years old, 125 centimetres tall.

  The clinic is for elderly patients with multiple chronic problems: failing heart, kidneys and lungs, dissolving bones and aching joints, bone marrow that’s drying up. In the name of efficiency, these patients cannot ask to see the same doctor at each appointment; they have to make do with whoever picks them up from the pile. They are old and complex and getting expensive – we wouldn’t want to spoil them. There is a desk between us, and I am supposed to type notes directly into the computer as they talk, as if I am a travel agent. Of course, most of these patients are deaf, so we spend the consultation shouting at each other. Apparently, a doctor who knows you and in whom you might trust is less important than that god Efficiency. I have the highest respect for rules I agree with, so I make an unofficial arrangement with the nurse coordinators to start seeing regularly my own cohort of patients. Irena becomes one of mine.