Slice Girls

by Joan Arakkal

  By the time I gained my general registration, we had moved to Perth. I set out to find a training position in orthopaedics. I came into Australia as a qualified orthopaedic surgeon, so I assumed I would be able to secure a training position, which is normally given to medical graduates with a few years of experience as a resident. I already had qualifications in the field, plus experience and good references to back it.

  The path to becoming an orthopaedic surgeon is a long one. First, a medical graduate spends a year as an intern. This is followed by few years of medical residency, working in different departments to get a taste for the various specialities. After this, a year or two is spent as a service registrar in orthopaedics. The holy grail is a trainee registrar position. Entry into these limited positions is highly contested and closely guarded. After four years as a trainee, they qualify to sit the FRACS exam and eventually emerge as an orthopaedic surgeon with a coveted FRACS diploma.

  The FRACS qualification, though by no means the only path, is a passport to registration as a specialist by the Medical Board of Australia. Hospital selection committees use the FRACS diploma and medical board registration as a preliminary screening criterion for selecting surgeons for specialist positions. This training bottleneck is heavily controlled by a private body, the Australian Orthopaedic Association (AOA). The number of training positions made available each year is inadequate to meet the demands of the market. This discrepancy in supply and demand helps protect the generous earnings and well-protected lifestyles of a lucky few. Selection into these artificially restricted registrar positions appears to be largely based on being associated with a boys’ club that privileges the privately-schooled children of the medical fraternity.

  When I first moved to Perth, I met a senior orthopaedic surgeon who was a Parsi, and a relative of the Dr Doctor I knew in Jamshedpur. When he heard of my aspirations to continue my orthopaedic career, he gently suggested I apply for training positions in plastic surgery. I realised much later that he was trying to tell me that orthopaedics in Western Australia was a closed shop. He knew that breaking into Perth’s orthopaedic community was going to be much harder for me than it had been for his forebears from Iran to blend into the Indian community all those years ago.

  On my first day at a Perth Hospital, I looked at the list of speciality registrars. There are two categories. ‘Trainee’ registrars are potential specialists at the end of four years and hold an elevated status, and ‘service’ registrars hope to be selected into the training program in the future. One name leapt out at me: Dr Dana Fred, one of the rare women in a long list of men. I imagined that we would be able to share the inevitable frustrations at work and enjoy a sense of sisterhood in this male-dominated workplace. I made my way to the outpatient department where she was working. I walked into her room with a smile and said, ‘You must be Dana. I’m Joan, a new service registrar in the hospital.’

  Her smile stopped at her lips. Awkwardly I withdrew my outstretched hand.

  ‘Is that your real name?’ she asked.

  Momentarily flummoxed, and trying to keep a straight face, I said, ‘No, it’s Bhagwathi Durga Laxmi, but you may call me Joan.’ She did not appear amused.

  In the UK, Cathy Lennox had taken me under her wing and smoothed out the ruffles that came my way. I respected her greatly, but a casual friendship was difficult because of her more senior position. Since then I had hoped to find a female surgical colleague. That hope was now fading quickly.

  Soon after, I was surprised to find Dana completely at ease with male colleagues, laughing with them and making indelicate jokes. I understood the dynamic that was at work. When women enter speciality training, particularly the surgical ones, they make a bargain. You can only join the club if you adopt its values and its swagger. In order to remain in the fold, you have to identify with the men. Part of this involves distancing themselves from other women. It appeared to me that women have to trade their individuality to be accepted into the masculine world of orthopaedics.

  I abandoned my attempts to befriend Dana, and it occurred to me how far women in the West still are from being truly liberated. Despite the barriers of poverty and access to education being largely lowered, our attitudes sometimes remain mired in archaic gender concepts. How can we truly call ourselves liberated if our ability to progress in our professions requires us to deny our female strengths and view each other as an adversary?

  The phone rang early one morning when Francis and I were still half asleep. He answered it and, after listening for a moment, asked the caller, ‘What has she done this time?’

  He turned to me and said, ‘You’re on the front page of the newspaper. You’re a “Slice Girl”. What’s that about?’

  The previous night, a reporter had come to the hospital to do a feature on the five female registrars in the surgical branches. Apparently, it was unusual to have that many women undergoing training at the same time in the hospital’s various surgical specialities. Unusual enough to warrant a news feature.

  When the reporter arrived, we gathered in an empty theatre in our green scrubs and he interviewed each of us in turn. The urology registrar was a rarity in her field – female urologists were as rare as their counterparts in orthopaedics – but it was easy to see how this motorcycling, skydiving bundle of energy slotted into a role where few women had ventured before her. She carried off her role with casual aplomb, handling male anatomy with a professional detachment that put everyone at ease.

  Then there were the two general surgery registrars. Vastly different in their personas, they were on common ground when they opened abdomens and operated on organs ranging from the mighty liver to the lowly appendix. In later years, one of them moved to endocrine surgery, with breast surgery forming a significant part of her work. I admired her grit and tenacity and the courage she showed in enduring harassment and bullying during her training. Her easy, friendly and unpretentious nature was at odds with the traditional persona of a surgeon. The attitudes of many of the male surgeons towards her was in keeping with the behaviour of the time. The reactions of some of the female surgeons were more interesting. They joined in the condemnation, as if to say to the men, ‘Accept me, I am one of you’.

  The orthopaedic registrar was in her first year of training. I had heard her say that she had been allowed to enter training because female representation was needed for reasons of political correctness.

  Then there was me. I was a service registrar in orthopaedics, which was an unaccredited position. As a relative newcomer to the medical circle of Perth, I was told I had to be seen and heard before I could apply for an accredited trainee registrar position.

  The reporter quickly finished his interview and then let loose with his camera. We stood in dignified poses, appropriate to future surgeons, as he clicked away. Soon he had plenty of pictures from which to choose. When he signalled that he was finished, we relaxed. He casually offered to take a few more shots, ‘Just for fun.’ With our guards down, we let our playful sides show.

  When Francis came home with the newspaper, I was unprepared for the photograph on the front page. It was from the end of the photo shoot. I was lying on the narrow operating table like a reclining Buddha. The other four registrars stood around me in various comical poses. The photo ‘for our eyes only’ was there for all to see.

  The article – headlined ‘Slice Girls’ – was also a far cry from the interviews. The reporter had embellished the feature almost to the point of ridiculousness. Though some of the women were unhappy with this casual portrayal, I was pleased that the public would see a side to us that was often hidden behind our sombre, harassed surgical countenances. I had always believed that, although we needed to take our work seriously, it was not necessary to take ourselves so. It did, however, cross my mind that a feature on five male surgical registrars might have been far less flippant – and featured fewer Poshes, Gingers, Sporties, Babies and Scaries!

  When I greeted Dr Tubb, the consultant I had been working w
ith, in the outpatient clinic that Monday, he said, ‘So what does your husband think of the picture in the paper?’ He had never enquired after my husband or family before, so his interest in Francis’s opinion confused me. As our conversation continued, I realised he was wondering if, as an Indian male, my husband was comfortable seeing his wife reclining in surgical fatigues in a newspaper.

  How was Dr Tubb to know that Kerala, where my parents were from, had a matrilineal system where women held sway over properties and were decision-makers in matters of note? How was he to know that there were more female goddesses than male gods in the Indian pantheon? How was he to know that the feminine had always been celebrated in the time-honoured lands of my ancestors?

  When most of your knowledge of India is garnered and extrapolated from films like Slumdog Millionaire or Leslee Udwin’s documentary India’s Daughter, it is easy to be blind to the other India that has shaken off the tyranny and shackles of colonisation.

  UNINSURED BONES

  As I continued to work in the various hospitals in Perth, I was keen to be seen by the consultants who would later sit in judgement of my abilities when the time came for selection into the training position. But it was proving to be harder than I thought. How could you be ‘seen’ by consultants who were ensconced in their own private work, well away from the public hospitals? I had noticed other registrars driving to visit the consultants in their private practice, taking X-rays and asking for clarifications. This was a good way for future trainees to build closer relationships with the men who mattered. I was uncomfortable with this arrangement.

  One Sunday evening, after I had been on call the entire weekend, I tidied up the theatre lists and attended to the orthopaedic ward patients on whom I’d operated earlier. Satisfied that everything was under control, I kicked off my shoes and lay down on the bed in the duty room. The exhaustion of the past forty-eight hours hit me but, just as my eyes closed, the piercing tone of my pager sounded. It was the emergency department. A seven-year-old girl with a broken elbow needed orthopaedic attention. I walked down the winding corridor to the emergency department where the registrar handed me the patient’s notes. I followed the nurse and traced the gentle whimper to a little blonde bundle behind the curtains of a cubicle.

  Jessy’s mother was distraught as she explained that her daughter had fallen out of her bunk bed an hour earlier. The nurse and I gently cut the sleeve of Jessy’s Winnie-the-Pooh pyjama shirt to expose her swollen elbow. I tried not to show my concern when I looked at the X-rays. The ‘nasty’ fracture classification, loosely used in the emergency department, seemed very appropriate when I saw the twisted fragments of the bone. Knowing that a swelling like this could press on the main artery in that region, I felt for Jessy’s pulse. It was hard to find. I picked up her hand and pressed on her nail bed. With some relief, I saw that it blanched and then turned pink when I released the pressure. At least the smaller arteries were doing their job.

  It was now close to midnight. I wanted to get Jessy into theatre, where I could manoeuvre the fracture into alignment and hold it in place with strong wires driven through the bone. I spoke to the anaesthetist and then telephoned the consultant on call, who I shall call Mr X. Over the weekend, I’d kept him informed of the orthopaedic patients who had come in, seeking approval for their treatment plans. Over the past forty-eight hours, he had stepped into the hospital only once, briefly, and I had run the patients past him.

  ‘Mr X, I have a seven-year-old with a Type IIIB supracondylar fracture and, while there is capillary return, her pulses are not palpable.’

  ‘So?’

  ‘I’ve booked the theatre but I’m concerned about getting a proper reduction. I may need your help with this one.’

  His response was very clear. I should just get on with it.

  With Jessy under anaesthesia, I manoeuvred the fractured pieces into place. The technician painstakingly kept shooting X-rays on the image intensifier as I positioned and repositioned Jessy’s arm, while also looking for a pulse in her wrist. When it was clear that the fracture was unusually challenging, I called Mr X again.

  ‘What do you want?’

  ‘Mr X, I am unable to get the fracture reduced through manipulation and I believe we need to open her. I would like your help.’

  After a few moments of silence, he said, ‘Open a book and do the operation.’

  When he hung up, I knew it was entirely up to me to set Jessy’s elbow properly and make sure that the blood supply was restored to her muscles and nerves so she was not left with a permanent deformity. I had little experience of handling such a severely broken bone in a child, but I did my best. With the fracture held in a position and the return of a faint pulse, I applied a plaster slab. Back in the paediatric ward, Jessy was diligently monitored and a close watch was kept over her warm, pink fingers.

  When I returned to the duty room, despite my physical and mental exhaustion, my brain felt as if it was on fire. Jessy could well have been my daughter.

  When morning came, Jessy was again taken to the operating theatre, this time with a full complement of staff. We opened Jessy’s swollen elbow and carefully cleared the muscle away from between the fractured ends, and the fragments locked into place. After ensuring the kinked artery was now pulsating in its rightful place, we drove wires across the fracture site. The wound was sutured and Jessy was wheeled into the post-operative area for the second time that morning.

  Jessy went on to make a good recovery. The wires were removed after the fracture had healed, leaving her with no deformity. Jessy’s mother tells me that her daughter now sleeps on the bottom bunk.

  I related to the mother and saw my little girl in Jessy. Was this how I would want my daughter’s fracture treated? If Jessy had come to the emergency department of a private hospital, she may have avoided a second trip to the theatre and all its associated risks. A well-funded public system was seemingly intentionally being run inefficiently; an inefficiency-by-design that curiously augments earnings. As the same group of orthopaedic surgeons control both the public and private systems, any diversion to the latter, where they can bill patients in an unrestrained fashion, is a profitable proposition.

  There was little I could do as a registrar to convince senior surgeons to leave their day practice or get out of bed at night to assist with a difficult situation in a public hospital.

  As I looked out of my study and saw six-year-old Sonia help her three-year-old brother climb a tree, the only thing I could do was make sure that our private health insurance policies were in order.

  ‘Did you know Paul might be thrown out of his training position?’ asked a registrar.

  I was surprised. ‘No. Why?’

  ‘He was found talking to a patient,’ he replied with a laugh.

  He was making a tongue-in-cheek comment about the culture of orthopaedics. In general, orthopaedic surgeons do not like talking to their patients and are not encouraged to do so. The few surgeons who choose to engage with their patients are seen as nonconformists. It is expected that by the time a patient enters a consulting room, their family doctor will already have worked out most of their non-orthopaedic medical issues. The surgeon focuses on the problem area. After a few questions, the scans go up on the illuminated X-ray screen. The excellent images provide the surgeon with most of the information he needs, so physical examinations are kept to a minimum. The majority of patients are potential candidates for surgery. After a quick examination, they are caught up in the procedures of signing consent forms, discussing costs and having further investigations done in preparation for their surgery. The paperwork is carefully monitored by diligent nurses and secretarial staff to ensure an efficient transfer of the patient’s name to an operating list. Any queries a patient has can be answered by the efficient staff working behind the scenes. Answering patients’ questions is an inefficient use of a surgeon’s valuable time. From the early days of training, the mantra ‘Time is money’ is entrenched into their psyche. They are ac
utely aware of the number of hours that can be spent relieving patients’ fears, explaining ailments or advising them about lifestyle changes that would improve their overall health.

  In my Perth consultation room, a young woman told me that nobody had examined her like this before. ‘The surgeon just looked at my MRI and booked me in for surgery.’

  It is true that advances in imaging reveal everything that is necessary to make a diagnosis, and that computer screens show blood results with the abnormal values highlighted for doctors to see at a glance. A torn ligament, a broken bone, a protruded spinal disc or a fragmented cartilage do not need to be imagined or palpated when an MRI has picked it up in all its detail. I reassured the woman that her surgeon did have all the information necessary to operate on her knee, and that the cruciate ligament he had repaired would serve her well. What I could not tell her was that the surgeon’s expensive car was probably purchased with the spoils of the numerous knee ligaments he had reconstructed, including her own. When time is money, and money is fast cars and yachts and expensive holidays, the rituals involved in examining a patient are sometimes sacrificed. For many surgeons, following in the footsteps of the guild masters, the finer arts of medicine are stamped out during their four years of training. Leaving inspection, palpation, percussion and auscultation to the traditionalists, these surgeons get straight to the business of fixing the broken bits that stare at them from their computer screens and X-ray boxes.

  But good medicine also involves listening, touching and talking.

  Leopold Auenbrugger, the Austrian who invented percussion as a diagnostic technique, and Dr Padmanabhan from my Indian medical school days taught us to see the person behind the indisposition. Today, too many of us see the problem long before we see the person.

  I heard of a young woman who was attending the chemotherapy suites for regular treatment. Her charm and wit reassured her oncologist and nurses that her treatment was proceeding well. She always sported a hat, and her fashionable dress sense was much admired, that is, until an oncology nurse inserting a cannula into her arm got a whiff of an unpleasant smell coming from her patient’s head. When the stylish hat was removed, the nurse was confronted by a lemon-sized fungating growth on the woman’s scalp. The patient’s cheerful smiles and bowler-style hat had disguised her fear and denial of the breast cancer that had found its way to her skull.