The Medicine

by Karen Hitchcock

  One of the last times I engaged in this behaviour myself was over a middle-aged patient with a rare neurological disorder – degenerative, untreatable – who came to the ED with worsening confusion and seizures that had probably been precipitated by a urinary tract infection. The neurology registrar and I faced off outside the patient’s cubicle. (Neither of us had seen the patient yet, but we knew his story and, when it came down to it, we both knew how to treat him.) I argued that neurology should take the patient as they had cared for him over the years, knew about his underlying disease and could best manage his seizures. The neurology registrar argued that the patient’s problem had a non-neurological cause (an infection) and so, even though it had resulted in a worsening of his neurological condition, someone else should manage the patient. “That’s crazy,” I said. “We’re not taking him,” the neuro reg said. The nurse pulled back the curtain and there was the patient, an emaciated man-boy in neat navy-blue pyjamas, his elderly parents sitting anxiously at either side of his bed. They’d heard everything.

  There are many reasons why intelligent, hardworking and generally humane doctors might argue fiercely in order to avoid taking patients: we may have a huge patient load already; we may be working with a less-than-physicianly consultant (boss) who would disparage us for accepting patients with problems outside her organ of interest; we may feel the patient will be better managed by someone else, as we may have no idea what to do. Also, for patients to be moved to a ward bed and be seen by a treating team quickly we need two things: a team to accept the patient, and a bed for them to go to.

  When a patient is in the ED, we registrars feel secure in the knowledge that someone is looking after them. The patient cubicles all open to a central area crowded with doctors and nurses. The ratio of staff to patients is high. Once we bring a patient to our ward they become our responsibility. This can be a large burden if our list is already full of patients who are still chaotically unwell. The undifferentiated patient is usually complicated: they take more time to sort out; they are generally older and may be frail, which means more things will go wrong and there is more chance of causing inadvertent harm with any treatment we give. And if we accept them early we must have the staff and the time to work out what is wrong, organise investigations and formulate a treatment plan. One solution to this has been the development of acute medical assessment units. Though these are set up to accept the patients early from the ED, they are still a work in progress at most hospitals in Australia. How many doctors and nurses do you need to look after a group of un-worked-up patients? We do not want acute medical assessment units to become chaotic, crowded holding bays with the atmosphere of a developing-world clinic: people twisted up in sheets and hanging skewed from beds, calling for a non-existent nurse.

  *

  The general physician in Australia had all but died out by the 1980s, everywhere except in the rural and remote hospitals that had neither the workforce nor the need for representatives of multiple sub-specialties. In the ’80s and ’90s there were virtually no general medicine physician trainees in Australia. The cities were in love with super sub-specialisation. Chapters were formed, training pathways developed. You didn’t just become a cardiologist, you became an electrophysiology cardiologist, or an interventional cardiologist, or an echo-cardiologist. You specialised in one kind of lung disease, or at the very least you specialised in a single organ. This was necessary in the face of a vast expansion in knowledge. Harrison’s Principles of Internal Medicine has 4012 pages. It is far more manageable to have to know only 300 of them in detail.

  In theory, all physicians receive a solid early training in general medicine: the holistic management of a patient, the concentrated juggling of the problems. We all sit the same exams after five years of working as a junior doctor, and then we all do three or four more years of specialty training. It is those final years that have become less focused on general medicine. And physicians differ in the extent to which they leave their generalist training behind them. I was on a ward round once, presenting a patient’s medical history to the consultant respiratory specialist, when he interrupted me with a huge theatrical yawn and asked when I was going to get to the bit about the lungs. He had no interest in hearing about the other things contributing to the patient’s decline: her heart, joints, bones and sugars. As far as he was concerned, I (the registrar) could fix them up myself or I could ignore them.

  I found it difficult to choose a sub-specialty. I chose neurology at first. I thought I might sub-sub-specialise within the discipline in multiple sclerosis, or acute stroke, or psychosomatic disorders. What could be cleverer than specialising in brains? I’d get to carry around gleaming equipment – ophthalmoscope, tuning forks, tendon hammers – in a shiny briefcase. I’d need a Chanel-red hatpin on hand at all times, to check a patient’s visual fields. I could be the next Oliver Sacks.

  For a year I participated in a general neurology clinic. It took me that long to admit it to myself: I loved my patients, but I was bored. No patient came because they could taste the colour green; no one mistook their wife for a hat. Patients turned up with two things: dizziness or headache. We’d rule out dangerous stuff like venous sinus thrombosis and cerebellar strokes and then give them reassurance or a pill.

  I tried nuclear medicine. It sounded very high-tech, and my mum loved that. I got to sit in a comfy wheelie chair in a quiet office with ambient lighting and endless cups of tea in my own cup and saucer, while I dictated reports about fuzzy scans of people with cancer or clots or broken bones. I looked for the black in the scan – that was the cancer. If someone had cancer metastases all through their bones, liver and lungs, we’d call it a Dalmatian scan and know they’d be dead in a few weeks. Lots of the people I scanned were slowly dying, but I didn’t know them. I was in another room, and the scanner didn’t pick up facial expressions. I would never have to be involved with a patient’s actual death – unless someone had a cardiac arrest in my scanner, and if that happened to a passenger on a bus, you wouldn’t expect the bus driver to fix her, would you? So there I sat, alone in a dark room with a bunch of fuzzy ugly scans, sipping another cup of tea.

  Next up I thought I’d try endocrinology, where I’d specialise in diabetes and out-of-control hormones. I like diabetes, especially the kind you get if you’re fat; I can relate to people who are struggling with the consequences of having done stuff they shouldn’t have. And I like to intervene in a disease process before the consequences become irreversible. But I just couldn’t get excited about the thyroid gland in the way all the endocrine bosses were, keen for treatment breakthroughs, keen to discuss whether we should palpate it, inject it, ablate it, scan it, irradiate it, or just watch it.

  There are many advantages to sub-specialisation for the doctor: when you say you’re an oncologist, everyone knows you administer medicine that dissolves bone marrow, fat and hair; people will open the door and let you go through first. And there are advantages for certain kinds of patients: if you are going to get an organ transplant, for example, it’s probably a very good idea to be treated by someone with expert knowledge of what happens to you when your blood is pumped by a heart harvested from another body and sewn into the cavity of your chest. But what if you are getting old and have a bit of this and a bit of that? What if your kidneys pack it in at the same time as your heart and so you can’t get an angiogram and there’s more going on than either your GP or the nephrologist with a special interest in the autoimmune glomerulonephritides is comfortable with?

  That general medicine was the only specialty for me became clear when I was treating an 84-year-old patient named Maria. I was working as a registrar on the respiratory unit and had been asked by another sub-specialty unit to take over her care as, in their opinion, her main problem was a chest infection. Before I met the patient I flicked through her notes. Her medical problems included emphysema requiring her to use continuous oxygen at home, congestive cardiac failure, multiple small strokes that had left her with a wea
k arm and chronic dizziness, atrial fibrillation, hypothyroidism, chronic daily headache and hypertension, and she had recently sustained a subdural brain haemorrhage in a fall. She was, at the time of my review, sporadically attending five separate sub-specialty clinics for the management of these problems. She lived with her daughter, who took sole care of her.

  Maria was lying in the hospital bed. I introduced myself and asked her why she had come to hospital the day before. “I have a chest infection,” she said. “Yes,” I said, “but what did you feel that made you come in to hospital yesterday?” She told me again that she had a chest infection, and that her GP said he couldn’t help her, that she needed medicine in her vein. “But can you describe to me what it was you felt, your symptoms?” “I felt a chest infection, a chest infection,” she repeated, like I was stupid not to see the obvious. “When did you last feel well?” “Why are you asking me all of these questions?” she asked grumpily. I said, equally grumpily, “You have a lot of health problems and I am trying to keep an open mind about what is wrong, and if you want me to help you then you have to answer my questions and there are going to be a lot of them.” We faced off for a moment. “Two months ago,” she said. “And what has changed since then in the way you feel?” I asked. She closed her eyes and sighed, then said she felt very tired and weak, she couldn’t walk around the house easily anymore, she’d fallen over a few times, she’d had a terrible cough a few months back but the sputum was now clear, her headaches were bad and she felt her heart palpitating in her chest sometimes. She opened her eyes and looked at me. “If my daughter was here she could tell you better.” I picked up her hand and told her I would examine her, look at her blood tests and then call her daughter.

  Even if Maria did have a chest infection, it was obvious that it was not her main problem: she needed to lose a bit of fluid; her heart rate needed slowing; her thyroid hormone levels needed checking; she needed to stop being prescribed so much prednisolone, which was contributing to her main problem of muscle weakness, which itself was probably a result of the de-conditioning that came with the immobility she had experienced during a chest infection a few months earlier. All of these medical problems needed sorting out, but above and beyond any medical management we could throw at her, what Maria needed was a course of physical rehabilitation if she was to return home with her daughter – which is what they both very much wanted. “I told Mum,” her daughter said to me on the telephone, crying, “if you can’t get out of bed, I can’t take care of you anymore.”

  As a representative of the respiratory unit my job was to take Maria under our bed card and prescribe antibiotics for her chest infection, if she had one. If she did not, in my opinion, have a chest infection, then it was my job to reject her, to leave her care in the hands of some other sub-specialty. But I saw that there was no subspecialty that Maria fitted into neatly. No one would want her under their bed card.

  Stories abound about patients who suffer the consequences of being treated ‘sub-specially’ by a sub-specialty. It happens on the surgical wards, too. I know of an elderly woman who recently fell and ripped a huge flap of skin off her elbow. She also had a sore hip. An X-ray of the hip was arranged in ED. The patient was admitted to the plastic surgeons who operated on her elbow. She recovered on the ward and was discharged home, but the pain in her hip worsened so she came back. The hip X-ray was reviewed in the ED – a week after it was taken. The plastic surgeons had taken exemplary care with her elbow. Too bad she had a snapped femur at the same time. They could not see beyond their own suture margins.

  The problem is clear enough: in massive hospitals demarcated into care silos there has been a loss of a holistic approach to the patient. This means that the medical care of the elderly and the crumbling has to be artificially fragmented into the care of separate organ systems. From a best-practice perspective, from a health resource perspective and from the perspective of Maria’s daughter, who was having to bring her to multiple appointments, what was chiefly needed was a good general physician to look after her, both as an inpatient and as an outpatient.

  Some hospitals without a general medicine unit roster on a daily “physician of last resort”. This consultant doctor and her team must take all the patients rejected by the other sub-specialist teams; for that day, they cannot say no. In other hospitals the registrars just argue and argue until one team gives in and accepts the “undifferentiated patient”. Either way it takes a long time for the patient to be admitted to the last resort. This situation is untenable. It is also inhumane and dangerous. Someone needs to want to look after these patients – the crumbles, the mysteries. A single team, headed by a doctor with expertise in treating a patient holistically, should direct their care. Yet these doctors – the general physicians – had become almost extinct.

  Fortunately, it’s dawning on authorities that the public needs hospitals and doctors to serve an ageing community among whom chronic diseases are on the rise; that hospitals need large general medical units with the staff, facilities and funding to scoop the chaotically unwell and the crumbling patients out of ED, to assess and treat them promptly and to go on caring for them till they are well. In Victoria, every major tertiary hospital has a general medicine department run by a mix of dual-trained physicians, general physicians and sub-specialists who either have a genuine interest in general medicine or who can’t get a job in their chosen field.

  Although there is still a dire shortage of committed generalists, there are now almost 300 registrars currently training to be general physicians. This shift in the delivery of specialist and hospital health care in Australia has brought with it a number of challenges. Having managed to attract this new generation of doctors to the practice of general medicine, we find we are unable to train them. To train as a general physician you are required by the Royal Australian College of Physicians to work two six-month sub-specialty terms. Finding departments that will employ general medicine trainees is proving extremely difficult, even when the trainee brings funding for most of her own salary. It seems sub-specialty departments on the whole do not wish to foster these strays; after fifty years of rapidly increasing medical knowledge, and the concomitant division of that knowledge into separate areas of practice based on organ systems, they want to produce doctors in their own image. Some sub-specialty associations are even putting in barriers to discourage their trainees from training both as a sub-specialist and a general physician, a combination that is especially valuable in rural areas where there may not be a full-time need for a cardiologist.

  *

  June arrives in my hospital’s emergency department. Fifteen minutes later the emergency consultant rings me: “We have a patient for you. Eighty-three-year-old woman living alone, found incontinent and confused. Stable, with a low-grade temperature. We’ve taken blood, urine, cultures and done a chest X-ray. May we send her up?”

  We have fifteen patients on our list, we’ve just received two new ones and they want us to accept June too. But yes, he may send her up. This is the rebirth of acute and general medicine as a specialty in Australia. We will see June in our acute assessment unit, start her on fluids and antibiotics and check her test results as they come through. She most likely has a urinary tract infection with associated delirium. Early treatment will increase her chances of getting better and getting home. We split our team and I’m relying on my junior registrar to let me know if anything dire or unexpected shows up in any of the patients I don’t have time to see. There’s no way my intern’s going home on time today; she’s juggling pathology forms and X-ray requests and faxes from other hospitals and scribbling like mad in the chart, translating my questions and the patient’s answers into a smooth narrative that explains why they’re here. Meanwhile her pager is going off and the nurses are harassing her for discharge summaries and scripts for other patients who are ready to leave. I’m thinking that another doctor or two and a few more nurses wouldn’t go astray here. The last resort may have had a makeover, but we’re
still a bit thin on the ground.

  Some Days

  Some days are pessimistic. You walk out the front door and overnight your bicycle’s become a reckless and lethal means of transport, so you walk to the tram stop grumbling and dodging pedestrians with eyes in their phones. Your clothes pinch and crease, your shoes are unstable, and your hair’s kinked all wrong. You’re crushed at the stop, then crushed on board. Gargantuan private-school backpacks bruise your ribs, people sneeze in your face, and when you try to look out of the only window that’s not plastered with ads, the guy sitting in front of it warily looks up from his screen every few seconds because he thinks you’re staring at him. So you stare at your knuckles white-gripping the pole. It’s all noxious stimuli and you know the wards will be overflowing with social catastrophes you can’t possibly fix and surely there was some other job you could have chosen? One that involved staying at home in your pyjamas, breezily chain-smoking (because you haven’t seen up close all those people drowning in air their lungs can no longer reap). A job where the boss wouldn’t haul you in for being consistently three to eight minutes late (bad role modelling for the juniors). Bins everywhere overflow with the disposable and your registrar cheerfully tells you she’s aiming for a single jam jar of rubbish per week. Which reminds you to stop at the supermarket on the way home to buy food that is palatable, nutritious and can be prepared in three to eight minutes for your children’s dinner. Which reminds you that you’ll be carrying it home in single-use plastic or adding to a collection of 99-cent reusable bags so mammoth it can no longer be housed. A jam jar’s so small. Your registrar’s optimism is glorious and exhausting and you are disinclined to see Planet Landfill as anything other than strange and tedious. Too far gone. The planet, your patients, your colleagues. You.