Monday, September 29, 2008

Just because I'm paranoid

...doesn't mean that the television isn't watching me!

For serious. Day 5 in VN and I'm wondering whether I'll have to get out by those same rickety boats. Man! All I wanted from this trip was to a) never enter a VN hospital lying down (and you thought the Australian public hospital system was bad...) and b) no melodrama of the hair-tearing variety.

One of the above is going well: I'm still standing, though mothership is currently undergoing the South (East Asia) Beach Diet...that's to say, massive gastro.

The other thing, not so great. My placement plans are in shambles due to a shitstorm that is some bizarre variation on Othello complete with misguided accusations of adultery and political intrigue. I'll write more when I can figure out how to protect the innocent. So far Desdemona hasn't copped it yet, but it's a possibility, and I could get dragged in as well.

Wednesday, September 24, 2008

Jetsetter

Hello from Sydney Airport, waiting for the plane to Vietnam. Yes, already! I barely got off the plane from Airlie Beach!

Too brain-dead at the moment to think. More later from the behind the high walls of state-controlled internet! Woohoot. Can you believe I"m going back to the country from which my relatives had to flee in rickety boats, only thirty years ago? And am going to be living in the enemy capital? Then again I also learned the language of the foreign devil colonialists to tertiary level...while barely speaking  my alleged mother tongue. Irony lives!

Friday, September 19, 2008

Before and after

One thing I've been noticing lately is that I have to stop and concentrate hard to remember what it was like being a layperson. Did I know what a clavicle or myocardial infarction was? How lungs work? What viruses and bacteria are? A lady recently asked the doctor how you get oxygen into your blood, and a guy asked whether you can trace the source of bacteria from a swab. Certainly the fact that antibiotics are for bacteria only clicked in med school for me.

It goes further than just knowledge, though. It's being grossed out - or not - by certain things. I don't blink an eye at blood or guts or vaginas, but purulent wounds still make me go ick. Can't remember if I used to be affected by such things. It's how I feel about hospitals nowadays. For normals, they can be a place of fear and grief. The feelings of claustrophobia, displacement and unease from when my grandma was sick occasionally come back to me: all those depressing neon lights, haggard faces and barely masked smells. After Armidale though, I feel at home in hospitals - even theatre is now familiar and cool. They've become a place of learning, where we seek out interesting and fun experiences - and some of those interesting and fun things are other people's illnesses. Kinda twisted really. I've never been an inpatient before (except as a hairy-backed preemie), and I imagine it's got to be disorienting. I remember, in law we read some Foucault, about the parallels between hospital and prison. You're stripped of power, put in a uniform, your movement is restricted, you live by others' schedules, people do things to you which you mightn't fully understand or consent to, and you're surveyed day and night.

In politics one of my lecturers talked about how it's difficult for democracies to fight in asymmetrical wars because citizens generally aren't happy to send their sons off to commit the brutalities that are often unavoidable when you're fighting unconventional forces (NB: much is debatable there bien sur). Obviously, this theory was derived from Vietnam-type conflicts. The way around this is professional standing armies, as opposed to concripts. You separate citizens from civil society to a boot camp in the bush, teach them loyalty to each other and the institution, show them how to function in extreme circumstances.

I find this an apt analogy for med school, in particular clinical rotations. Besides the teaching of facts and skills, they help to transform us from wet-eared civvies into hard-assed troops. You learn the ethos, conventions, secret language, and see and perform things that would be considered horrors in other settings. Sticking a needle in someone's back or a finger in their bum. Cutting them open, exposing organs, then shoving everything back in again. Kinda absurd if you think about it. What's amazing is that this sort of initiation isn't uncommon. Nurses, undertakers, cops, firemen, carers, social workers, vets, soldiers, hell even dunny cleaners! Entire classes of otherwise normal people to whom weird-to-Joe-Average things are routine.

Some of the hardening is necessary of course. You can't have a doctor getting disgusted or freaked out every time they come across an anal abscess or something. But it's also a bit dehumanising, because dodging the discomfort of the situation also disconnects you from the patient's experience. I reckon it's a good thing to stand back once in a while and think, yeah, to normal people, this here is weird, embarassing, absurd, scary or gross. Like taking your own pulse, it tethers you back to your own humanity, the kid who lurks behind the professional.

Wednesday, September 17, 2008

Overheard

In the waiting room:
"I've been having trouble with Bubba - he throws a tantrum and cries and spits when I try to breastfeed him!"
"Really? I've heard of babies that couldn't latch on well, but never one that actually hates breastfeeding..."
"Do you reckon it predicts whether he'll be a boob or butt man when he's grown up?"
More from Doc:
"All the Muslims want to take over the world and kill everyone....you're not Muslim are you?"

He also wants to invade Mexico and to tell his friend Malcolm Turnbull (our new Liberal [actually conservative] opposition leader, FYI non-Aussies) to scrap "socialised medicine" cos it creates too much paperwork.

We also had a patient today who was a former SAS officer (the CIA apparently wanted to recruit him once). His theory is that Muslim society is afflicted by inbreeding and the recessive genes make tards who are recruited as martyrs.

Monday, September 15, 2008

Teo and tangents

So I just finished watching the Enough Rope interview with Maverick Neurosurgeon Charlie Teo. Thought-provoking stuff. If you don't know his background, read on at Australian Story and Enough Rope.

The name Charlie Teo first crossed my consciousness this year, when I met one of his patients during my rural GP week. She'd had a tumour on her spinal cord and was handballed between various surgeons who told her it was impossible to remove. None of them mentioned Teo, the surgeon who was willing to operate on the inoperable. They were finally referred to him when the tumour was far advanced. They got to him just in time to save her life, but she was already a quadriplegic at that point. This lady and her husband were fair dinkum Aussie Battlers, and I say that without irony. Her husband had his own health problems - chronic severe back pain, multiple injuries from past car accidents, and was visiting the GP with pneumonia, requiring hospitalisation - but still managed to care for her full time. Despite their ordeals, they were philosophical, not at all self-pitying, and deeply committed to each other in an unsentimental, no-nonsense way.

To me, the Outcast Teo vs Medical Fraternity fracas highlights the contradictions in our noble profession. Questioning the validity of Teo's techniques is justifiable, but the visceral hatred he seems to evoke from the establishment goes far beyond the scientific. It comes from something baser, something like insecurity and jealousy and resentment.

See, on one hand there are the bright lights - doctors who inspire with their integrity, passion, intellectual precision, curiosity, compassion, humility, dedication and conscientiousness. I've seen these qualities in doctors at all levels, from humble residents, to GPs, to consultants (ie. Gods). I see the potential in many of my fellow students. The docs I had in Armidale were awesome. Being a small hospital, the structure was really flat - consultants actually deigned to talk to us lowly students and treated us as really really really junior colleagues. And they could teach, hallelujah!

On the other hand, I'm always wondering what patients would think if they really knew what doctors are like backstage. They are given so much trust, and abuse of that trust is so commonplace. Not so much the Dr Evil "mutilating genitals during surgery for kicks" kind of thing, but insidious, small betrayals. Using big words to take advantage of patients' ignorance. Never, ever saying "I don't know". Making referrals to specialists who've been nice to you, or not making referrals to specialists who've slighted you once. Putting on a fa├žade of professional reassurance, only to talk crap about them behind their back. Using bias-based, not evidence-based medicine. Blaming patients for depression or addiction. Being careless with infection control. Doing tests or procedures that aren't strictly necessary to cover your own ass or make a bigger buck. Never admitting mistakes. Writing off some patients as basket cases, too hard, or not worth the bother. Aiming for "good enough not to be sued" rather than best care. I could go on and on. And the personalities, god, the personalities. Impenetrable vanity, arrogance, selfishness, apathy, laziness, bullying. I mean, I'm sure these things occur in all professions - petty rivalries and so forth. But people's LIVES aren't at stake in other professions, people's lives don't depend on whether Dr X's pride has been wounded or not.

I'm on Flynnie placement yet again, and in moments of particularly brain-numbing boredom I fantasise about the scathing portrait of my boss' foibles I'm going to write. A by-product of observing him for most of my waking hours. Let me try to capture some of his flavour. Our protagonist is a late-40's American ex-surgeon, a footballer who injured himself out of a career in college, dressed in all-American blue jeans and polo shirts. Adopts a folksy straight-shooting manner but bullshits his way around questions he can't answer ("What's idioventricular mean? It's something that's not working like it's supposed to. Like idiopathic, idiosyncrasy, one of those old Greek word things"). FoxNews devotee, son of a blue-collar worker, now multi-millionaire, casually racist ("Med school was so hard back in the day that two guys from my class killed themselves. Just couldn't hack the pace. They were both Arabs from Pakistan or something. Good thing too. Those people are all terrorists in the making"). He's threatened by and contemptuous of anyone who dares question his authority by showing any knowledge about their condition or using alternative therapies . Starts lots of sentences with "In medicine...", eg. "In medicine, this is called a puritic [sic] rash". Writes referral letters with really bad spelling and grammar. Asks "guess what I'm thinking!" kinds of questions to show off his knowledge or exert his power rather than actually discussing or teaching. Is impervious to student's eyes glazing over during his lengthy Pearls O' Homegrown Wisdom About Medicine - which he repeats. A lot.

A recent consultation went like this. A gentle, child-of-hippies type of woman comes in with diarrhoea and constipation.
Her: I had a look on the internet...and I know I shouldn't try to self-diagnose, but I was wondering if it could possibly be IBS?
Doc: Impossible. Can't believe anything on the internet. Inflammatory Bowel Disease is a very serious condition and it is very unlikely you have it...(etc etc etc etc)
Me: Um. Didn't she mean Irritable Bowel Syndrome?
Her: Yes, that's it. So I tried some natural medicines they recommended at the shop over there...
Doc instantly bristles, patronises her ("Cactus extract? What kind of cactus? There are many many kinds of cactus"), contradicts everything she says, and boots her out. After she leaves, he launches into lecture mode.
That there was a good lesson for you. What they don't teach you nowadays in medical school, which they did back in the days when I was training, is that you should never, ever let the patient take control. You'll see. When you've had 30 years of experience like me, you find out all patients want to use and abuse you. They'll come in with some scrap they've found off the Google and try to sell you some bullshit. Like that girl just then, she just flung piles and piles of bullshit all over the room. I picked it up right away, as soon as she came in - I've got my observations honed to perfection, it'll take you 30 years to get that kind of skill. Cactus extract! You saw how she tried to get her agenda on, but no way, I don't stand for that shit. You gotta learn that you're the doctor and you're the boss. She's a massage therapist - probably flunked out of high school - and she wants to tell YOU what to do! (etc etc etc etc)
Somewhere, an artsy-fartsy tie-died hippy-dippy anatomy-sucks ethics-roolz Newie lecturer is weeping. To be fair, I don't want to completely vilify him. He's got his charm and is great with babies. He works up his patients really thoroughly and goes the extra mile for them...at least the ones he likes. I can tolerate him...and occasionally learn a thing or two, though I now take whatever he says with a fistful of salt - he's quite capable of making up facts.

Praps I have this impossible ideal of Perfect Doctor - one that others, and no doubt I myself, will constantly fall short of. But the standard's got to be at least: "how would I like to be treated? what if it was my grandma?".

Tuesday, September 9, 2008

Ritual

First you have to get through the negotiations. You introduce yourself as a student and exchange pleasantries and nervous jokes. You put on your shiniest Bedside Manner, perky and polite. Almost invariably, they consent with self-deprecating good nature. Everyone's got to learn some time, right? I'm happy to help if I can. Yes, thank you so much - I really appreciate it. If you feel uncomfortable at any time, please let me know and I'll stop. Your group and tutor are standing around you, sometimes participating in this exchange, but often just silent spectators at the show.

It's a shifting of power. Once you have given them the semblance of control, you proceed to command them to perform all sorts of bizarre manoeuvres. Could you take off your shirt, please? And would you mind if I pulled your pants down a little further? Is it ok if I put my hand here in your groin? This is someone who could be your grandmother's age, or your father's. In everyday life, you would perhaps nod at each other on a sidewalk, or if you met, you would defer to them as your elder and better. Now, circumstances have contrived that you both meet here, in this place of delicately balanced vulnerabilities. You have to get past your own anxious voices. Am I doing it wrong? Do they all think I'm a tard? Am I making it up, or do I really feel this? Am I hurting them? This is embarassing.

But when you're in the zone, when you've passed all the awkwardness and anxiety and come to focus, finally the physical examination becomes an oasis. The laying on of hands, the strict order of the tests and the calm solemnity recall the rituals of the ancients. Feel a pulse - make sure it is not your own. Put your hand on a heart. Listen. The room is quiet, the clatter of the hospital fades into the background, and all you can hear is the heart beat and breathing. A steady rhythm, almost music. One-two, one-two. It is a moment of strange intimacy.