The Medicine

by Karen Hitchcock

  An American comedian once riffed that he refused to buy his daughters mobile phones because, he said, they arrested the development of empathy and kindness by removing the part of communication that is the real-time witnessing of someone’s reaction. He gave the example of a child calling someone “fat” face to face versus in a text: seeing the other person’s pain made the name-caller feel bad, whereas the texter simply felt victorious. Perhaps with increasingly sophisticated technology the ability to interpret another’s response will cease to be socially valuable or necessary. Why can’t computers do it for us, if the interpretive “rules” have been so clearly mapped? Perhaps it will be a big relief to us all, given that looking into a fellow human being’s eyes is evidently so socially risky and intellectually taxing. Given that looking has become more invasion than inquiry.

  Love, Fear and Hierarchy

  The first teacher I fell in love with was the fill-in librarian. I was in Grade 4. I’d finally finished the moronic “class readers” and had thus earned access to the library, a vast wonderland I had no idea how to navigate alone. I trailed along behind the librarian as she slipped novels from the shelves and handed them to me one by one. The world turned humid. I thought my heart might explode. The next was a laconic cardiologist in his late fifties with a full head of grey hair. I was a third-year medical student on a cardiology rotation. I’d stay back late, and we’d go over the electrocardiograms, or watch the echocardiograms of the hearts I’d listened to on the ward that day so I could see if I’d correctly diagnosed the murmurs. He had broad, strong hands, a bone-dry sense of humour and nothing more important to do than see patients and teach. He knew everything, could do anything. He must have known. Sometimes he’d meet my adoring gaze and his mouth would freeze mid-word, his finger hovering over the ECG. But then he’d clear his throat, straighten his big square glasses and point out the missing QRS complexes: the reason our patient was passing out.

  I think now of that old cardiologist and I know it was not exactly him I loved. It was what he offered me: the knowledge and the skill. I remember, so when some intern starts following me around like a puppy with a wagging tongue, I don’t feel flattered. I know it’s not really about me.

  Medicine is a practice you learn by apprenticeship. Lectures, assignments and exams are necessary, but you get the actual know-how from your bosses on the wards and in the theatres. The bosses: dozens of individuals living their own smooth and rocky lives, with their bell-curving interpersonal skills and their own genealogy of masters. From them you learn how to be.

  There’s no fuel for learning as potent or as combustible as love. Except perhaps fear: of personal humiliation or of killing someone. Without fear or love motivating all of this work, there’s just the strict hierarchy to keep patients safe. Despite a lifelong allergy to authority, as a junior I felt mostly protected by my low standing: I was drowning in uncertainty and ignorance and constantly thanking God the buck didn’t stop with me. There’s a lot to be said for the value of humility in a discipline where you’ll never, ever know it all.

  I once had a bright fifth-year student attached to my team. During ward rounds I’d be explaining to the patient some planned investigation or treatment, or gently broaching the idea that they might die, and she’d leap into my every pause with chirpy re-explanations or repeatedly interrupt me mid-sentence with an unskilled authority that was breathtaking. I took her aside, told her not to interrupt me and explained that I paused not because I was struggling for words but to give the patient time to think or speak. The next day I discovered she’d switched to my male colleague’s team. When our paths crossed she’d look at me with pure hatred. I can imagine what she told her friends: “Dr Hitchcock, that total bitch.” I could have savaged her, insisted she get her arse back on my ward round, but I let it pass. And my colleague – tall, nice suits, awfully charming – said she never interrupted him once.

  It can get very intense with all that raw and fallible humanity crashing about as we move through the wards in ordered formation – all day, every day, trusting that everyone is relentlessly giving a damn. All so you don’t find yourself in front of a dead patient’s husband, saying, “I’m so sorry she bled to death, sir, but ‘we’ forgot to check the haemoglobin.”

  If you believe the headlines, intimidation and bullying are endemic and widely condoned in medicine: they’re basically our modus operandi. That’s not true, though they occur. And if you stuff up catastrophically, no one expects it all to stay polite.

  Power is so easy to abuse or forget. As a boss you always get the best seat and go through the door first. Your trainees think you know it all, and if they don’t think that they’ll pretend they do to score a good reference. How easy it would be to believe you actually are amazing. How easy to take your midlife crisis into the late-night private tutorial and demand that she-who-adores-you-for-your-know-how tend your flagging ego.

  It’s terrible, really, to think of all the ways we tend a powerful person’s ego: the insincere compliments offered; the behaviours excused out of fear, love or hierarchy. Respect morphing into pander, demanded or not: dutifully laughing at some esteemed professor’s endless, unfunny jokes.

  I once knew a great surgeon, short, fiery and fierce. He was one of the best in the country, did heroic, unthinkably dexterous things with a scalpel. Registrars trembled in admiration and fear. In the middle of a ward round he’d often eviscerate the less-favoured trainees. In theatre he might yell and insult them. He was a total prick, but there was no one more skilled at taking a knife to your belly. There’s probably one roaming every large hospital: periodically uncontained and grandiose, always technically brilliant. Medicine’s miscreant rock stars. Witnesses to his performance would look at their shoes till he was done, because this little sadist was also the man who’d taught them, nurtured them, screamed at them, then rescued them (and the patient’s life) when they were elbow-deep in someone’s guts and didn’t know where to cut next. The bullied junior is sacrificed to love, fear and hierarchy – the very three things that make the entire system work.

  What the Hell Was I Afraid Of?

  Fear, they say, has an object, whereas anxiety floats more freely, attaching to nothing in particular, or to everything. The two roles that have stirred in me the most fear and anxiety are that of doctor and that of mother. The latter is made worse, no doubt, by being a mother who is a doctor: being constantly confronted with real-life examples of the terrible things that actually can happen. I was unable to watch my twin daughters on playground swings when they were toddlers as it made me sick with fear. I’d get their father to supervise, then crouch somewhere and wait. I heard of an emergency physician who made his kids wear crash helmets in the playground. But that wouldn’t protect their tiny necks, would it? And now, what’s a swing compared with the mangling car crash that is female adolescence in this world? Those headlines, the abuse, glass ceilings, primping, plastics and porn. How to protect them and still let them play? How to arm them, internally?

  On a plane a few months ago, the guy-in-a-suit next to me splayed his Australian newspaper wide open such that half the paper (and his fist) curtained the front of my face, while the bottom edge of the paper stroked my thigh. I turned and stared at him. But he just kept on importantly reading his important newspaper, in his space and mine. I cleared my throat. I wriggled. Coined unspoken protests. I could have politely said, “Excuse me?” I could have gently nudged the fist-paper-package over to his side of the plane. I didn’t. I assumed his manoeuvre was purposeful – him staking a claim – and it made me feel small and later enraged, at him and at myself. It was a trivial event, but I thought a lot about my reaction. What the hell was I afraid of? An imaginary patriarchy?

  I’ve been punched in the face, called a filthy slut, a cunt, a moll, a dog. I’ve been groped and catcalled and propositioned. I’ve had a guy scream that I should watch him “cum all over the floor” as he aimed his stream of piss at me. All the perpetrators were patients u
nder my care, out of their minds with delirium, dementia or psychosis; drug-addled, tumour-riddled or dying. I took no offence. I was not harmed (the puncher was a very frail 85-year-old woman). I have only rarely feared for my physical safety at work. In clinical situations, the kinds of abuse that are sound-minded, premeditated and purposeful are usually perpetrated by doctors (a minority of doctors) against their patients or against their staff. Which is unsurprising, given it’s the doctors who are generally in the position of power.

  What would you do if you could get away with it, if you could ignore all the rules and suffer no consequences? What pleasures would you indulge, what shortcuts would you take, what part of the social contract would you ignore? What would you ask for if you knew no one would ever say no?

  At a literary festival some years ago, Bret Easton Ellis commented that people would do anything to get a part in a movie. He paused, looked us one by one in the eye and said, “Anything.” I wonder what it must be like to be an A-grade celebrity or head of state or boss of some giant corporation. To be surrounded by admirers, flatterers, assistants, dependants. To be always met by applause, agreement and cheer, as if the entire world were your cartoon wife, smoothing her skirt, fixing her smile, quietening the kids and filling your glass at the sound of your car in the driveway.

  They say every country, every town, every institution, every workplace, every home has its own unspoken caste system. For a minute, an hour, or days on end we’ll inhabit a small universe with its particular power structures and then bounce out into another. In some we are powerful, in some we are at risk. One minute you’re a CEO and the next you’re half-naked on a stretcher, being allocated a medical record number and triaged into a vast emergency room, whimpering. Competent mother to squashed on a bus to end of the queue at Centrelink.

  It’s been many years since I’ve been in a situation in which getting the sack from a place of work would render me destitute. So, for now, I’m protected from whatever combination of desire, fear or need would compel me to do “anything”. I recognise that such a position is privileged. I also have power over others – my patients, my juniors, my children. It’s not absolute, and neither is it simple or all one way. It’s a huge responsibility, given that I care for their wellbeing. And I invite them – patient, registrar, child – to question, to disagree, discuss, decline. Part of my job as the “powerful” one is to empower my charges. Speak up. I’m listening. You won’t wound my ego. Nothing’s off the table. What a thrill it is to help a girl find and use her voice. Teaching those who can to speak up. Allowing them to.

  Yesterday, one of my daughters was in a fit of rage over “feminine hygiene products”. She hasn’t started menstruating yet, but she’d just heard (on YouTube) that tampons are taxed as a luxury item. “Tampons!” she said, her eyes bulging, hands on her hips. “Extravagant, indulgent, bloody tampons are a luxury item?” She paused and looked me in the eye. “So. Fucking. Sexist.” And I was like: right on, daughter.

  The Biggest Decisions

  Researchers relate “decision fatigue” in executives to the degradation of sound judgement and to poor impulse control after hours. Nearing the end of a weekend of dealing with a ward full of sick patients, and faced with a particularly challenging case, I recognise I have it by my own sudden irritability and my desire to decide anything, for a bit of relief. Rather than start saying stupid things in an authoritative tone and driving a Maserati I don’t own 200 kilometres an hour down some freeway, I tell my registrar I’ll be back in fifteen minutes and walk to my office.

  Each year, medical errors cause hundreds of patient deaths in Australia. Decision-making processes are therefore interesting to educators and researchers seeking to reduce avoidable harm. You see your GP and your blood pressure is elevated: whether you will be prescribed a drug or not depends on your “risk profile” – whether you smoke, have diabetes, have cardiovascular disease – and also on your doctor’s threshold for prescribing. The doctor will hopefully include you in the decision-making process, but he or she still needs to recommend a particular course of action and tell you why. The drug must be chosen from one of dozens on the market. Each decision is made through a mix of scientific methodology, pattern recognition, probability and personal opinion.

  National consensus guidelines offer basic treatment algorithms for all the common diseases. If a patient has a chronic lung disease, you can check these guidelines and prescribe what is considered to be best current practice. There are websites with “consumer decision-making tools” where patients can type in their own data and get a computer-generated recommendation. There are also equations and scoring systems, far too many to remember, so we carry them around in apps. The Wells score determines the likelihood that a breathless patient has a blood clot in their lung; the CHA2DS2-VASc score guides the prescription of anticoagulants by determining the risk of stroke from a fibrillating heart; the Child–Pugh score (based on tests for blood albumin, bilirubin and clotting, fluid in the abdomen and degree of brain malfunction) is used to work out how long a patient with a failing liver has to live. Should a drug be prescribed for osteoporosis? Type in the patient’s data and get an answer. There are protocols in hospital for the treatment of disasters like heart attacks, catastrophic haemorrhage and community-acquired pneumonia. These are designed to guide decision-making and reduce human error, and are helpful if the patient’s body follows protocol. But if I followed the guidelines for all of the diseases afflicting my typical elderly patient, she would be on twenty-one medications and I would be killing her.

  Hippocrates said that it is more important to know what kind of patient the disease has than what kind of disease the patient has. You’d think the body would be more straightforward; we don’t have that many organs and only five of them are vital. Sometimes you just don’t know exactly what to do: you study the form, consult your mates and the major online encyclopedias, take an educated gamble, then sit back and watch the race, sweating bullets. Maybe that’s why some people hate doctors, those culpable, imperfect decision-making machines.

  As a trainee you pass the difficult decisions to the boss, with relief. But now I am the boss, and I have a young patient with pneumonia and 2 litres of bacteria-filled pus collecting outside his lungs, making him septic and delirious. The treatment is intravenous antibiotics and surgical drainage. But the patient’s liver is failing after a decade of serious drinking; it no longer makes clotting factors, so his blood is thin and he may bleed to death if the surgeons cut into his chest. His heart is straining; his brain is faltering in a bath of blood-borne toxins. He will likely die without the operation. He will likely die with the operation.

  The patient laughs and pulls his blanket over his head when I outline his options. His only living relative tells us to do what we think is best. The surgeons say it’s my call. So do the infectious-diseases physician and the gastroenterologist. The anaesthetist says he’ll intubate him but estimates that he has a 70 per cent chance of death. My team of junior doctors look at me expectantly, trusting that I have the answer. There is no protocol, no app that can share the responsibility.

  All day I have that feeling you get when you take a step and think you’ll hit pavement but your foot falls unexpectedly into a gutter. No sooner have I convinced myself that it would be futile to put him through surgery than I think, “Well, why not put him through the surgery? What have we got to lose?” Even Hippocrates knew that “when the entire lung is inflamed … he will live for two or three days”.

  He could die on the table, but then again he might wake up with a clean chest cavity and say thanks. According to his Child–Pugh score, he could last three more years. You can do a lot in three years.

  My other patients, with simpler combinations of pneumonia, dehydration, intoxication, and heart and kidney failure, recede in their crisp white beds. Their treatments are settled; all they need for today are time and medicine.

  I tell my registrar I’ll be back, go to my office, and pick up a
book about a journalist and a doctor who may or may not be a murderer. I never wanted to be a lawyer, because laws are just made-up rules. I never wanted to be a gambler, because I don’t believe in luck. I drink a glass of water and walk back to the ward. I take the patient’s file – that poor sick man – and write a summary, each of his vital organs listed and followed by its narrative of failure. It is useful, to see the facts reduced to a story in a format that approaches an equation that ends with a decision.

  Doing the Right Thing

  Nineteen years old, crawling through a BA, and I was sitting in a crowded theatre, listening to the hippest philosophy lecturer on campus. She looked like a sexy elf: tiny, with burlesque-red lips, and hands that illustrated every sentence with curlicues. We were all in love with her, a feeling intensified by the subject matter: philosophy and the body. Philosophy at the time was all postmodernism, late-wave feminism and psychoanalysis; as promised, this subject took us through those fun parks, but only after we’d endured a month of bloody Maurice Merleau-Ponty.

  Philosophy seemed like a terrifyingly attractive secret-knowledge club: a guide to life, written over thousands of years. But where to start? The guy who’d broken my heart the year before had been a big Nietzsche fan. He had the T-shirt and everything. It was a major part of his allure.

  Later, in med school, I didn’t get to choose subjects. One of the things I had to study was bioethics: a kind of applied philosophy for future doctors, and a nice reprieve from biochemistry. There was no mention of the self as an “intersubjective field”, nor the “noetic-noematic experience”. We did bioethics to learn the rules of good doctorly behaviour. And, according to our lecturer, we’d fly through the exam, and practise sound medicine, if we simply remembered the four foundational principles: autonomy, beneficence, non-maleficence and justice. Roughly translated, they suggested you respect your patient’s wishes, do good without causing harm and give a thought to greater society.