The Medicine

by Karen Hitchcock

  The boss shrugged. “Look, the hospital’s on a hill; we have beds, a generator, plenty of Weet-Bix …”

  I flew my family in the next day. My daughters spent the weeks splashing round in their gumboots, playing with fat green frogs and catching tadpoles. In the hospital we did the best we could. A son brought in his elderly mother, who’d been forcefully evacuated from her semi-submerged home. She gripped her chest, gasping for breath. “The looters … They’re out there in boats.” The town was melting down.

  The waters receded, and I went to a smaller, even more remote hospital. I flew in and out each week on an eight-seater toy plane. The airport was filled with happy farmers’ wives, their arms full of children. The air was so humid your clothes were instantly damp; the hospital was so cold the patients shivered and we all wore jackets. Besides the bonded intern – a tall farm boy, super smart, who spoke a slow-drawling English – I was the only Australian-trained doctor. The tough Aussie nurses ran the show, bossing the doctors and keeping their eyes on the duds. They were often the only thing standing between the patients and death. They gave me gifts: enormous duck eggs with shells that felt and looked like old-fashioned linen; 1940s sunglasses with Bakelite frames, left behind when an old lady died; stickers for my children. They pushed squares of chocolate into my palm with a wink. I was constantly thinking that they should’ve been getting the big cheques.

  A man back in town after city surgery for facial fractures came in overnight with a headache and fever. He was sent to the ward by a doctor who spoke very poor English. In the morning I read the scant notes and walked onto the ward to find the patient white and shaking. I started intravenous fluids, got the intern to take blood cultures and checked the computer for the patient’s most recent results. He’d had a scan overnight that had revealed a collection of fluid in his brain, a fact that the overnight registrar had failed to mention. I called the patient’s neurosurgeon in Brisbane, thinking it was likely a complication of the surgery needing his urgent attention. “So was it CSF leaking from his nose or not?” the surgeon snapped. CSF: cerebrospinal fluid, the sugary liquid that bathes and floats the brain. “Excuse me?” I said, thinking he must have confused a couple of patients. “I was called at 2 a.m., and I asked them to check if the nasal discharge was CSF.” “What nasal discharge?” I said, increasingly alarmed, it being no small thing to have a leaking skull along with a pool of something potentially expanding in your brain.

  I trotted to the patient, phone clamped to my ear. “Is your nose running?” “Yep.” Resisting the urge to cry into the phone “It wasn’t me. It was that guy from overnight”, I asked the surgeon how I could tell if it was CSF. Laboratory testing would have to be sent to the city and could take days. He sighed, not unkindly. “Use a urine-test dipstick. If it’s glucose positive, it’s CSF.”

  I held a plastic cup under the patient’s nose: he snorted out a stream of crystal-clear fluid. I twirled the stick. Positive.

  “Jesus Christ,” said the surgeon.

  I called the helicopter retrieval team.

  I love my city job. The neurosurgeons – should I require them – are two floors down. The need for rural doctors is extreme, but Médecins Sans Frontières won’t send you to the back of Bourke. Recently I’ve read a number of agitated newsletters from locum agencies, commenting on the increased number of doctors we’ve started to graduate in Australia. They claim that there is no doctor shortage, that these new graduates will flood the market. That there’ll be no place for them to go.

  Working Regional

  In late 2016, I resigned from my full-time city-hospital job. I still worked there – a clinic or two each week, a few months on the wards each year – but not every day. I thought I had the money thing sorted. Turns out I owned my time outright, but had to pay the mortgage and everything else by Visa.

  It’s April 2017. I find myself in a small town in Western Australia, 5000 kilometres from home, working at a regional hospital. When I was a registrar I swore I’d never locum again, but here I am, broke enough to leave my daughters for a month, camping someplace they can’t convince enough doctors to live in. They put me up in a three-bedroom brick holiday unit. There are rooms of small single beds, kids squealing in the pool. The beach is across the road behind a scrubby sand dune. When I open my front door, I can hear the ocean roar and smell rotting seaweed, but I don’t go and look. I close all the curtains and turn the air conditioner on full. The unit has the same prison-like rough-hewn bricks inside and out. Sand from the cement between the bricks showers my bed day and night, as if I’m being forced to sleep in it as punishment for ignoring the beach.

  The town is working class, with colossal unemployment and a large Indigenous population. I don’t see a European car for an entire month. I walk through the shopping centre to the supermarket. I’m the only one wearing a suit, the only one in heels. The only person who smiles at me is the gay check-out guy, who asks where I’m from and – ignoring the queue – tells me all about his recent escapades in Brisbane.

  Big or small, town or country, hospitals are mostly the same: the sick flock, the staff doing what they can. This hospital has no subspecialty doctors and no intensive care ward. There are just three general physicians and our teams of junior staff. If the patient is too sick or their disease too strange, we fly them to Perth. I ship out a man with Guillain–Barré syndrome (sort of like polio), a few with big heart attacks and one massive pulmonary embolism. The old, the can’t-cope, the pneumonias and the failing hearts stay with us. As do the attempted suicides, the young alcohol-rotted livers, the bad teeth and the nowhere-else-to-sleeps.

  The two permanent physicians are excellent immigrant doctors, smart, without bravado and happily working the wards all year long. They recommend afternoon trips and offer me dinners, but I’m on a tight schedule: wake, exercise hard, work, eat lettuce and plain yoghurt, watch Netflix, sleep. I talk to my daughters daily by telephone, FaceTime or Skype. I order them Uber-delivered gelato, close my eyes and imagine them eating. Each night I watch a TV show about a group of perfectly diverse, beautiful lesbians who all have high-powered careers and yet manage to spend much of the day in cafes, clubs, each other’s beds and high drama. Even if they have children.

  The hospital has a handful of Australian-trained interns, but the majority of its registrars and residents were educated overseas. Some are highly experienced specialists who couldn’t bear the trauma of repeating – or are bracing themselves to repeat – years of training to fulfil Australian requirements. One or two come from a pool of virtually unemployables, hired now and then by desperately short-staffed hospitals. As the locum I cop the dodgy team. My resident is unable to understand spoken English unless it’s relayed in slow staccato. He can follow one-step commands, but seems unable to think. On our rounds I make him carry a piece of paper upon which he is to note his accumulating tasks. I tell him it’s not a list of jobs, it’s a list of things to do so our patients don’t die. My registrar has just arrived in town and – when he gets off his email and does look at me – offers only belligerence or indifference. He believes documenting medical history and physical findings or his discussions with doctors in Perth to be a waste of time. He neglects to check the repeat blood tests on patients with catastrophic electrolyte imbalances, and when I explain that preventing cardiac arrest is part of his job he yells at me. The only way I can explain the pair’s complete lack of curiosity about or concern for our patients is that the patients are not real people to them. I attend the bedside of a distressed, old white patient surrounded by doctors and nurses from around the globe. When the patient catches sight of me he calls out, “Finally, someone normal.” Perhaps it’s a kind of poetic justice that the place is staffed by refugees.

  On my last day before I fly home I treat a woman with advanced lung cancer. She’s not old but has one of those faces desiccated by decades of hard work and harder smoking. We drain 2 litres of fluid out of her chest so that she can breathe. She tells me she’s o
nly just found out that she has eight months to live. Then looks at me, waiting. I pull up a chair. She grimaces in pain from the tube hanging out between her ribs but refuses analgesia. I convince her. We talk. She starts to cry. “I never cry,” she says. “I can usually keep meself together.” I hold her hand, which she has edged towards me. I say, “You can cry here … It’s all too terrible. But we’ll get the drain out this afternoon and you’ll be able to go home to your family.” She keeps crying. I keep hold of her hand. “Bev,” I say, “you have hundreds of days left to live. Hundreds of days.” She looks at me, wipes her eyes. I say, “So, go home and live the shit out of them.” And then we are both laughing.

  Ill Communication

  At my hospital we’re interviewing medical students for their first job and I feel sorry for them, all dressed up in their best suits, hair washed and shiny, fingers still aching from their final exams. I’m no good at scoring humans out of five. How might a “one” present? A three? They’re all smart, hardworking and know what to say, so don’t tell me the score hinges on much more than the panel member’s prejudice. The first had a handful of extra degrees, spent her summers saving lives in scary countries and was confident, articulate and gorgeous. She was definitely a five. The administrative representative on the panel hit the roof. Apparently, no one gets a five. Ever. “In that case it should be out of four,” I said, then pulled rank: “She’s a five.”

  I’ll probably always give the intimidating girls a five.

  I came to medicine straight from the English department, so that I could become a psychoanalyst and bill Medicare. I didn’t tell them that in my interview (and I ended up a physician). What I told them was inconsequential as there was a push to get more humanities graduates into med school: apparently we’d make better communicators; apparently we’d be more humane. I don’t know who started these rumours, but they mustn’t have met the boys from my philosophy tutes.

  The move to medicine was a bit of a shock: one minute I’m quietly reading, smoking Sobranies, the next I’m dissecting a dead torso. It was like high-school science class, with gore. At that time, around the country, medical students were being taught and examined on the skills of communication. Laudable, in theory. According to the course literature, communication skills seemed to mean every aspect of being a doctor that wasn’t based on hard science. In practice it seemed to mean “how to tell the patient …” Despite my coveted humanities background, each year I’d barely pass. In my final year I was examined by one of the course coordinators, a middle-aged man who had a habit of rolling his eyes up into the back of his head whenever he had to speak or listen to someone. He also wore huge glasses that he’d push up and down his nose as he spoke: anything not to meet your gaze as he taught you the essentials of human interaction. In the exam, he was the patient and I’d be looking at him, trying to explain in a caring, open-ended yet honest and supportive way that he was going to die from colon cancer, and away his eyes would fly, leaving me to stare at a pair of boiled egg whites. Eye contact, I wanted to scream. Have you ever heard of eye contact? Instead, I gave him his prognosis and he gave me my feedback: two point five.

  Most of the communication-skills tutors disliked medical students. Once, standing in a shower cubicle at the university pool, I overheard a couple of tutors making fun of one of us: “You should have heard him explaining to the actor why he needed to do her pap smear. It was disgraceful. He had no idea.” “Yeah,” said the other, “it’s the same every year. You wonder where they get them.” The tutors came from other departments, ones with less funding for innovative programs to teach students how to communicate. I would have hated us, too.

  I wondered if “communication” could be taught at all. Say it like this and don’t cross your arms, lean forward ever so slightly and nod your head. It was as though they were teaching robots to resemble humans, and meanwhile our work would be piling up and we’d all be shitting ourselves about biochemistry. The fact that medical schools were trying to select the more communication-savvy students at interview suggests they had the same doubts. Suddenly more women got in than did men: hooray. But if you only let in students who are warm, empathic, excellent raconteurs, who’ll do the lab-based and management jobs? Who’ll teach communication skills?

  The science part of medicine can be taught. But the rest, the human aspects – how to listen, how to be present, how to help your patient bear their suffering – you can’t quantify, distil or institute. You can’t even teach someone to pretend. It’s hard to say what the essential aspects of human connection are, but I’m picturing Marina Abramović, the Serbian performance artist; in 2010, she sat on a hard chair in the centre of a room at New York’s Museum of Modern Art, from nine to five every day for three months. You took a number and, when it was your turn, you sat in front of her silently, and she would look into your eyes – attend to you – for as long as you wished. Some people sat for three minutes, some for five hours. When you left she would close her eyes and rest until the next sitter came. I have the book that documents in photos the faces of those who sat with her. Most of them are crying, cracked wide open by her offer of a benign, focused attention, by nothing more than Abramović opening her eyes.

  The Eyes Have It

  I’ve been thinking about eyes a lot lately, mainly because mine are defective. I am what they call a “high myope”, so without really strong glasses or contact lenses the world ends 10 centimetres in front of my face. Last year I had a threatened retinal detachment, and just recently I scratched my cornea on the bedside table while pawing for my glasses in the dark. Ophthalmologists are the only doctors for whom I semi-willingly become a patient, because I’m terrified of going blind. I couldn’t read books. I couldn’t read people.

  Wordless eye contact is undoubtedly a richly communicative exchange. If we are to believe the poets and popular lore, it’s all about the eyes. And it does feel as if it is. But how is it possible for an emotion to be expressed in an eyeball? Unless it’s true that we have a “soul” and that this soul is visible in our eyes, which I wish I could believe. Besides the changing aperture of the pupil, the eyeball itself is essentially inert. So if not from the eye then from where does the love, hate, pain or fear pour? What do we actually read in each other?

  Of course when we look at each other we see more than a pair of isolated eyeballs. Even if limited to the eye region of the face, we have eyebrows, eyelids and all the intricate skin-bound structures around the eye that contribute to non-verbal emotional expression. But the communicative capacities of the eyeball alone have received a lot of attention from researchers.

  Of all the world’s animals, humans have by far the largest visible sclera (white of the eye) surrounding the dark iris. This enables us to accurately judge the direction of someone’s gaze, even at a distance, and to know what captures their attention. Lots of white indicates fear or surprise. There are the variations in blink rate and gaze duration to decode. Pupils widen in states of fear or sexual arousal, and current research seems to confirm the ancient belief that we unconsciously find large pupils attractive. How did the ancients know this and believe it so faithfully that women risked blindness by bucketing belladonna into their eyeballs?

  An online test developed at the University of Cambridge (search for “Social Intelligence Test”) measures your ability to interpret another’s emotional state. The test presents you with thirty-six separate photos of faces cropped down to just a few centimetres above and below the eyes. For each photo, you choose between four emotions (jealousy, fear, suspicion and happiness, for example). One emotion is correct and the rest are wrong. Apparently, a score above thirty correctly identified emotions indicates a high emotional sensitivity, and one below twenty-two might explain certain challenges you’ve faced in interpersonal relationships. Some of the cropped faces are taken from centuries-old portraits, so it’s not like the scientists asked the subjects how they actually felt. But what’s the alternative? Faces are rich with information that
we interpret consciously and unconsciously. As with a spoken language, how we produce and read these signs is influenced by our culture, but there seems to be a baseline language nonetheless.

  Generally, direct eye contact is valued in Western culture. But it turns out that “direct eye contact” is a game with intricate rules we’re not taught (beyond the basics) and understand only instinctively, if at all. Scientists have attempted to define this unspoken language of eye contact, and I read a lot of this work before a clinic last week and found myself increasingly self-conscious: watching how I watch. They say that your “eye contact” becomes “staring” when your blink rate slows and your eyes fix. I have spent a lot of time staring. You’re not supposed to look directly into people’s eyes for too long (experts offer varying time limits) or it’s interpretable as a threat or a come-on, and except for limited circumstances (a stand-off, the bedroom) it is socially inappropriate. Instead, I read, one’s eyes should casually flit around the other person’s eye area. Not the lips (sexual). Not the forehead (threatening). Japanese kids are taught to stare at their teacher’s neck. I longed for such a rule. In the clinic I had my computer, my notes, and the timing of my blink rate and gaze sites to help me avoid my habitual, socially treacherous direct gaze. I wanted my patients to feel at ease, that I was attentive and non-judgemental, not some threatening sexual predator. I didn’t want to invade.

  Eye contact requires high-level cognitive resources and it can therefore inhibit our ability to think – why in conversation it’s common to look away momentarily when trying to formulate a complex thought or recall something half-remembered. Media trainers advise you to focus on the bridge of an interviewer’s nose to prevent distraction. Freud sat behind his patients. We avoid the eyes to harness our resources.