The Medicine

by Karen Hitchcock

  The medical board had received a complaint from a patient’s mother, about me. They enclosed the complaint: three pages of hysterical accusations that I had mistreated her 22-year-old son. They advised me to contact my medical defence organisation before I lodged my response, which would be reviewed by a panel that would decide what action, if any, to pursue. I walked home without blinking, closed my study door and pressed my face into a cushion so I didn’t wake my family. All those years of study, worry and sacrifice and now I’d be sacked, struck off. When I thought I could talk, I called my mentor and friend, Mike, a physician in his sixties. Then I called the hospital’s lawyer, then my boss, then my best friend. Everyone told me not to worry.

  They say “impostor syndrome” (the belief you have your position by mistake and will eventually be found out) is more common among women. Among physicians, it’s almost universal to feel it now and then. Once you’ve crammed your way through the hoops early in your career, there’s no clear way to measure your competence and absolutely no way to know everything, to never miss anything, to never make a mistake. How do you judge yourself? By your cure rate? Most modern diseases – chronic, non-communicable, lifestyle – aren’t curable. Your death rate? It’s actually quite difficult to bump someone off, and everyone experiences the very occasional close call. Bedside manner? Who’s to be the judge of that?

  Self-perception aside, ensuring a doctor’s ongoing competency is clearly important for the community. Internationally, governments, insurance companies, institutions and specialist colleges all wield various assessment tools. Like any set of performance indicators, they narrowly define the clinical work as a collection of measurable, lowest-common-denominator actions. It’s not hard to teach (and work) to a test. But if that’s the best we can do and those markers keep patients safe, then I suppose that’s tolerable.

  Doctors can also be assessed via patient surveys, with varying results. In the US it turned out that some of the doctors with the highest ratings were the ones handing out opiates and benzodiazepines like they were party favours. Multiple studies show that many GPs are reluctant to discuss their patients’ weight – even if it’s the cause of their diseases – for fear they’ll offend. Is this perhaps because there are searchable websites now that allow you to post reviews of your doctor as if she’s a restaurant?

  Recently, one of my friends was erroneously listed as a “sure thing” to get you on the Disability Support Pension. He only found out after a rash of patients showed up with Centrelink forms at the ready. Imagine if he cared about ratings? Imagine if his job depended on them?

  Despite all talk to the contrary, the consumer model of medicine is a disaster. If you know what you want and you’re willing to pay for it, then the person to call is your dealer. Patients aren’t customers, consumers or clients. It’s a relationship, not a service. The beauty of Medicare is that it enables the transaction to remain purely ethical. Who’d ever pay for tough love?

  I was terrified and then ashamed about that complaint. I knew the mother’s claims were false and vindictive, but they hit me at the peak of my insecurity. Maybe I had inadvertently mistreated this young man, missed something, hurt him.

  I’d seen the patient and his mother four times. For years they’d seen – and continued to see – numerous other doctors. The young man had been investigated since childhood for symptoms that were consistently, eventually, determined to be “out of keeping”, “mysterious” or “not clearly organic”. He’d been tested and retested. I was initially tempted to do the same but instead brought a senior colleague in to review him. At our last appointment he was finally seeing a psychologist and a personal trainer, and had enrolled in university. Soon after, the mother emailed me, requesting that I declare him permanently unfit for work. It was there in my early notes: “Mother: Munchausen by proxy??”

  As a doctor you must retain the ability and the right to refuse a patient’s demand, or the demands of their loved ones, or the demands of the institutions that pay your wages. To do so you have to keep your anxiety in check, act only in your patient’s best interests, read your reviews like a novelist might (that is, noting who wrote them), and trust that the board, your peers, your quadruple-checking fear of missing something will keep you on the safe side of sorry.

  As I reviewed and re-reviewed my notes like a cop, as I wrote and rewrote my response, my terror and shame turned to righteous anger, then to deep sadness for the mother and her son. They let the aggrieved party read your response. A kind of closing clinical intervention. Please, I wanted to write, please let him be. In the final exonerating draft, I summarised the case gently but without ambiguity. “I’m so sorry,” I wrote, “and I truly hope you find someone who can help.”

  Do No Harm

  A few weeks ago I killed a patient. The patient wasn’t someone I’d met a few times on a ward round, them in extremis, their personal characteristics all out of focus. I’d known Jim since I was a registrar.

  We met in an outpatient clinic. He was in his mid-eighties, tall and solidly built with neatly clipped white hair. He had severe osteoarthritis of the spine, which had fused the bones of his neck and fixed his head at a downward angle. He walked with a polished wooden stick. He had usually attended one of the recently closed community clinics and was put out at having to come to the hospital.

  How was he? Fine. Anything to report? No. I listened to his heart, his lungs. “So,” I said, “what do you do?”

  He shifted in his seat. “Oh, I have a few jobs.”

  “What are they?”

  For our eyes to meet he had to turn his head sideways and roll his eyes to the side. He did that for the first time, briefly. “You don’t have time.”

  “I’m having a slow day. Tell me.”

  He delivered pamphlets and cleaned houses, for exercise. He had once been a professional florist and now made bouquets of dried flowers. “As you can see, it makes a mess of my nails.”

  He started on the past, a story he continued over the years of our meetings. In his forties he’d had his heart broken by his long-term boyfriend and had never recovered, the way some people don’t.

  “Look at you,” he said in his slightly British camp, mopping his eyes. “Sitting there, psychoanalysing me. You’re so … present.”

  He called me “darling” or “delicious”. If I wasn’t rostered for the clinic when he had an appointment, the nurses would call me so I could run up from the wards to say hello. He made my family a bouquet of holly and berries for Christmas last year. So when I saw his name on the list of overnight admissions, I said, “He’s one of mine.”

  With my registrars and intern I walked to the emergency department, where Jim was waiting for a ward bed. The curtains around his cubicle were drawn. I peeked in. He was standing up, head down, trying to urinate into a bottle. We waited outside. “Damn it all,” he cursed. Seeing our shoes lined up under the curtain, he said, “It’s all right, come in.” He twisted his head sideways and saw me. “Oh darling, I’m so relieved it’s you.” He started to cry. “It’s too terrible,” he said, holding his hospital-issue pyjamas up in one fist, empty bottle in the other. “I can’t pass water and …” – he lowered his voice – “I’ve just dirtied myself. I’m so ashamed.”

  I reached up and hugged him. He rested his big skull on my shoulder. “Don’t worry, we’ll take care of you.”

  He had a badly infected ulcer on one heel that needed antibiotics, and a blood clot in a deep vein of one calf that I wasn’t sure what to do about. I checked the guidelines and called a colleague: anticoagulation, for six weeks.

  He improved slowly. The morning after he’d started holding court from his crisp white bed, I walked in and his face was pale, his hands like marble. He said he was scared, that something was wrong. His blood pressure dropped. My mind flipped through the differentials. I laid my palm on his cold forehead and told him everything would be okay. We called a code. The intensive care team arrived. Ten of us crowded around him, sticking
him full of IV lines, taking blood tests, pumping him with fluid. He groaned when I pushed his abdomen, and I was cold with dread. The surgeons arrived and wheeled him away to the scanner. I stood in the steel-lined pan room, eyes closed, hand against the wall.

  He’d lost a couple of litres of blood directly into a large muscle in his back: a small artery with a fragile spot on its wall antagonised by my anticoagulant treatment. They sedated and intubated him, tried to block the artery, sliced him open from breastbone to pubis, transfused him, flooded him with inotropes, filtered his blood.

  I went to see him in the intensive care unit. His grand old body, splayed out on a metal bed, his split abdomen held together temporarily with surgical tape. Tubes to and from his neck, bladder, arms, belly, down his throat. His vitals, up in multicoloured lights, all of them utterly, unreassuringly, within the normal range. Jim. A sack of skin left at a crime scene and kept pink with machinery, saline, drugs and blood. The ICU physician looked at my face. “We’re doing everything we can … But it’s fifty-fifty.”

  The retrospectoscope is a medical instrument a doctor wields against herself or – in spite and relief – against a colleague. You look back through this scope and see that you should have or shouldn’t have, you would have or wouldn’t have. I trawled through the notes, the tests, rechecked the guidelines, consulted clinical studies – I could have elected not to anticoagulate. I could have waited. Many wouldn’t, but I could have. I sweated and flinched.

  I dragged myself to work each day, hollowed out and refilled with something dense and very heavy. I came home, fell asleep immediately and stayed that way till morning. My colleagues uttered words of comfort. “Don’t worry about me,” I said. “I’m not the one who’s dead.”

  I met with Mike, my physician friend and mentor. I told him the whole thing from the beginning. “Yes, you killed him,” he said. “You’re a doctor, not a naturopath, so you gotta treat people … and sometimes it kills them. I tell you what I wouldn’t have done – held a man who’d just defecated on himself. I’m not sure I could’ve done that.”

  I wiped my eyes with the back of my hands. “If you’d known Jim, you could have.”

  The Student Lottery

  A few years ago, at a friend’s barbecue, a worldly and usually quite articulate man – whom I knew in the way you know a friend of a friend – stopped telling me where to buy and how to cook the best sausages in Melbourne and started bemoaning the injustice of graduate-entry degrees. “I’ve paid hundreds of thousands of dollars in private-school fees so my children can get into medicine or law if they choose to, and then the unis go and change the rules!” At many universities in Australia, you now need a basic undergraduate degree before you can apply to study any of the lucrative professions. I smiled sweetly. “P’raps,” I said, “there’s a way you can pay for your kids to be spoonfed through their undergraduate degrees too?”

  Lots of people want to be doctors. Why is that, really? I mean, I’d highly recommend it as a job: it’s mostly interesting, requires no small talk, and you don’t get bossed around very much. And essentially – at least as a physician – you get paid to listen and to think, two things I’d happily do for free. But when you’re conducting medical-school admissions interviews, the answer you hear to the why-do-you-want-to-be-a-doctor question is most often some variation on “To help people.” Which is usually bullshit. (Or, if it’s not, it soon will be.) Even if the student’s conscious aim is to embark upon a career that will “help people”, there’s generally some other quest behind or beside that altruistic urge: the quest for knowledge, power, money, discovery, respect, glory, stable employment, a genderless title. If all you wanted was to help, there are plenty of understaffed homeless shelters desperate for a fresh set of hands. Teachers, social workers and nurses all help people, but there aren’t ten applicants for every place in those disciplines.

  All over the world, doctors are respected and respectfully remunerated. How medical schools choose among the big pool of hopefuls is a subject constantly debated in institutions and journals. When I was at high school in the ’80s you needed to study science and score around 100 per cent in your final exams to get in to medicine. I didn’t know any doctors besides the awkward local GP, being a doctor had never crossed my mind, and, if it had, I wouldn’t have had a chance in hell of getting in. But in the past few decades medical schools have been trying to choose those who they think will make the best doctors rather than the best students. Yes, you can imagine the debates.

  Entry criteria vary from campus to campus. Most universities in Australia use some combination of academic achievement, “personality test” and interview. For a long time now, Dutch universities have chosen almost all of their students by lottery (and most studies show that these randoms perform just as well as the students they’ve hand-picked). You don’t need to be exceptionally smart to be a good doctor. Medical school’s not hard, it’s just lots. The marks competition – like the lottery – is simply a cost-efficient, completely transparent cull.

  The University of Newcastle’s medical school was the first in Australia to propose entry criteria based on more than pure marks. The school was founded in 1975 by a group of medical education radicals who suffered fierce opposition from the establishment. Not only because they changed the focus from rote to discovery, and threw the students into the hospitals from day one (rather than year four), but also because they suggested that the best future doctors aren’t necessarily high-school students with exam marks in the top 0.5 per cent. (Full disclosure: in 1998, to my great astonishment, they let me in.)

  It’s hard to argue that the ideal medical workforce should be mono in culture, class and gender, which was what traditional entrance requirements typically got you. Come from the same place, hang out together every day for another five or six years, maybe get a few lectures on cultural diversity, and then flood the entire country.

  Look at the statistics: your life is largely determined by where you’re born and what you can afford to buy there. A lottery, if you will. And if all you can afford is cheap bread and entry to a local school that is overcrowded, under-resourced and has no playground because it was hocked in the ’90s, well, the odds that you’ll get diabetes and not get into medicine are pretty good.

  The groups who are least represented in higher education – especially in medicine – are also those with the poorest health: people from low socio-economic backgrounds, and Indigenous Australians. Two-tiered private/public everything doesn’t help. But when it comes to tertiary education, studies consistently show that one of the major barriers to these groups even applying is the perception that they do not belong there.

  The Newcastle founders wanted not only more Aboriginal health content – dire-looking graphs, hands-on cultural exposure – but also more Aboriginal medical graduates. They took their idea to Indigenous communities and proposed modified entrance criteria that made allowance for social disadvantage. There were complaints, from parents who claimed it was “unfair” and a way of “stealing” places from those who’d “earned” them. The government agreed to fund an additional four places to silence the “unfair advantage” arguments. (It’s funny, there are never headlines suggesting that maybe it’s unfair to pay many tens of thousands for kids to be pimped up to scratch.)

  The University of Newcastle currently has sixty Indigenous students studying medicine across two campuses. A dedicated unit offers cultural, pastoral and academic support. There are around 200 Indigenous doctors now practising in Australia – we need ten times that number to reach population parity. Whether these doctors end up directing health policy or working in Darwin or in Macquarie Street, they stand as the most powerful symbol of what is possible for those who’ve never won any kind of lottery.

  The Rural Doctor Problem

  Rural and remote hospitals are chronically short of doctors, and they rely on locum agencies to source staff. The agencies recruit aggressively: I used to receive a couple of emails each week
. Fancy a stint on the sunny coast? These rates are not to be missed! The closer the start date the more money the agencies offer, like a discount hotel website with a reverse economy. If you refer a friend, they give you a loaded credit card. For as long as the hospital has you, the agency will earn a doctor’s salary, simply for arranging the hook-up.

  I did a locum stint as a registrar in 2010 during a six-month break in my training. The pay wrenched me from the city, but it also filled me with guilt: what junior doctor could be worth a public hospital paying that much? What job could be that bad?

  I was midway through a placement in northern Queensland when the rain started and didn’t stop. The waters quickly rose until they were lapping at my doormat. Roads became speeding rivers. The roof of the pathology lab collapsed, so all the blood tests had to be flown to Brisbane. There was no milk, bread or fresh vegetables. I started to think of the rain as a thing with character and malicious intent. I dreamed of galleries and trams.

  On a Wednesday morning we heard that the airport would close on Friday. Patients who needed transfer would have to be choppered out from the roof. The itinerant staff could stay and be trapped in the town “indefinitely” or they could leave on the last flights. Doctors drained from the hospital. My family had been planning to join me the following week. I couldn’t bring four-year-old twins into a flood zone, and I couldn’t be away from them “indefinitely”. Standing in our full ward, I told my intern I might have to leave. He looked at me, swallowed and looked away. “Don’t worry,” he said to the floor. “I’ll be fine.”