Thursday, June 29, 2017

The Truth About Medicine... Most People In It Think It Sucks. But There Are Ways We Can Fix This.


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The day I got into medicine, was the greatest day of my life. 

I'm sure many medical students and doctors would tell you the exact same thing...

I'd always wanted to study medicine. "What better job was there?" I thought. You could save lives and live in relative comfort your entire life. I'd get to emulate my childhood hero growing up, Captain Hawkeye Pierce from M.A.S.H. 


But after leukaemia struck my life... it became personal. 


I wanted to help people as I'd been helped. It was my doctor's words; that "The Good News Is You're 17 and You Have Leukaemia, but the Bad News is You're 17, And You Have Leukaemia..." and his actions that got me to believe that I actually had a chance in this... It was another patients' words the day before my transplant that really sunk in, and changed my life. Imagine being in a position to do that for people everyday!

My first day in medicine was one of the most joyful of my life. 

I was so excited to finally be in a position to give back, and so delighted to be alongside so many other people who cared just as me. 


But as time went on... things changed. 


For me, and for many of my classmates too. 

As I progressed through the course, I got more and more burdened with work, and more and more indoctrinated (pardon the pun) into the collective Group-Think of modern medicine. One which emphasised speed over accuracy, marks over competence. One which measured success through KPIs such as reduced wait times and greater efficiency rather than reduced morbility and morbidity, and higher patient satisfaction and involvement. As everyone in this profession does. 

Doctors have one of the highest rates of depression of any profession. 

They are highest in suicide. 

They have the highest rates of alcoholism too. 

1/4 medical students are majorly depressed, and more than 1/10 will think about suicide in any given year. 


And this in a population who are most educated about mental illness, and the fact that they are illnesses, not just an abstract constructs or "excuses," as many still widely suggest and believe. Somehow still, amongst those with depression or severe symptoms of depression, only 15% of medical students actually get help... For doctors... the rates are even lower

Why is this happening though? 

Aren't these people being paid heaps? 

Don't they know the risks of the disease, and how altered biochemistry can alter your very mental state - your very person? 

Well, there are many reasons why. 

This article gives great explanations as to why. 

Various personality traits and attitudes make doctors more likely to suffer from depression. 

Perfectionists, narcicists, compulsiveness, martryism, and disparaging views of vulnerability are all commonplace. Facing death, watching good people suffer, and losing the battle over and over again also burdens doctors. Burnout from stress affects 45% of doctors, ladies and senior physicians in particular. And as this article puts so poignantly, Osler, the founder of the first American residency program, advocating for steadiness in physicians, was perhaps the largest contributor to all this... 


Many doctors feel that showing weakness is a failure on their part. 


If they're not steady under pressure, how can they serve their patients? 

And that can be a tough burden to bear...

400 doctors take their own lives in America alone.
An entire medical school's worth...




Junior doctors and medical students have similarly sky-high rates of depression and suicide ideation (the 10% figure is a conservative estimate; studies in my nation show , but have the added pressure of exams and the weight of expectations on their shoulders too. 
Furthermore, other factors, such as living on their own for the first time, often overseas for many students (where the added pressure of maintaining a steady income is another burden), high levels of student debt, and the sheer pressure of the course and succeeding itself plagues many students. 

Many of my medical student and junior doctors friends complain about many of the above stresses. Many feel medicine takes over their lives. In a time where they should be out and enjoying their life, many students, as well as doctors, regret not enjoying life more. And many feel disillusioned too. They feel they were misled about what medicine actually was. About the impact they have. About the difference they make. So many of my friends express this in particular. But the toxic, competitive hospital environment, where specialty spots are limited, the medical heirachy is emphasised (and perpetuated by older doctors in an "If I went through it, they should too" manner) and bullying is rife, also pushes many young meddies over the edge. 

Very recently, in my country, Australia, 3 junior doctors took their lives within one week

THREE. YOUNG. LIVES...

With so much to look forward to.

In. One. Week. 

2 people I knew took their own life last year. 
1 was an old school mate of mine. 


What can we do about it then? I guess that's the question that remains. 

Well, dealing with how doctors perceive themselves and mental illness is one step in the right direction. 

Letting doctors be human



This great TED Talk, one of the highest rated of all time I believe, discusses the expectation of doctor perfection, and how this counter-intuitively actually worsens patient outcomes. 

When doctors feel they have to be perfect, that their mistakes are their fault, a great burden is placed on their head. 

It's important to be competent, don't get me wrong. But this unreal expectation of perfection is what, as Brian Goldman points out here, is only harming doctors more. 

We're not learning from it right now. There's no mandatory reporting of issues or near misses in hospitals. More recently, at a quality and safety lecture I attended, I learned there was one in our hospitals in my state in Australia, but that it was under-utilized, and something feared by doctors, as opposed to the learning tool it was intended to be. 

Something as simple as a place for doctors to confess mistakes, and seek sympathy from other doctors, could change the lives of hundreds of thousands of silently suffering, perfection seeking, burned out medicos. And it could improve patient outcomes too. 

Of course, it needs to be a done in a sensitive manner. Perhaps confidentially, with identification being made impossible. Though it's horrible that some die due to lapses in doctors' concentration, as pointed out in this article, overworked doctors, facing physical and emotional stress, are less competent ones. Hundreds of thousands will die due to medical error this year alone - medical error is estimated to be the third highest killer in the American medical system. 

The numbers are alarming, to be sure. But not learning from mistakes, not making diagnostic/prescribing/treatment processes better, and not giving doctors a place to vent, and relax, is only going to increase this number if anything. 

A great TED talk by a very interesting man - Atul Gawande (highly recommend his books on medicine and how to fix it), discussing a simple process which reduced mortality in surgeries by as much as 40% - a checklist. These little innovations and improvements are necessary to accomplish the end goal of saving more lives and reducing suffering!  

Coping with loss


But reducing medical error alone isn't the only way we can ease doctors' strife. 

Loss is something many doctors have to face. 

And it's a big contributor to doctor and medical student dissatisfaction. 


I can only imagine how going to work everyday, knowing that you're going to witness suffering, pain and death can be soul-wrenching. I certainly do feel disillusioned when walking through wards and seeing the same story, of a seemingly nice person, suddenly finding their health deteriorating, and then, in most cases, never reaching their whole selves again... Indeed, my first brush with depression was due to loss. 


But if there's one thing I wish I could tell all doctors... It's this.


You can ALWAYS make a difference in peoples' lives!


No matter what their position, no matter what their outcome.


The things I remember, and thank my doctors for aren't their medical decisions or prowess, but rather those times they went above and beyond the call to talk, treat and look after me. I'll never forget the first words of my doctors, the words that made me realise that I DID have a choice in how I viewed all this... The words that helped me resolve to, at the tender age of 17, focus on what I COULD control rather than the horrible things I couldn't - including death. I'll never forget the time one doctor decided to chill in my room while I was hallucinating and horribly weak. Having someone there to ground me made a huge difference. I'll never forget the letter he wrote to the medical board that's allowing me to live my dream today and I'll never forget the time I walked into my doctor's room instead of onto the railway tracks, and I'll never forget the feeling I felt at that time - that I was being cared for. 

I can never thank them enough for all of this. 

And those things... they took nothing from them, mere moments if anything... and yet they've changed my life. 

And those small things... they could be done by anyone, at anytime too. 

And they mean the world to people.  

I have friends who've passed away from this disease whose families we stay in touch with. They say those little moments, the barbeque we threw and invited them to on a whim on Father's Day, the game of snakes and ladders we played while their father lay on a deathbed smiling, they're things they'll always remember.




It needn't be as large as this. A simple display of humanity in an experience lacking any could mean everything to someone. Something as small as a glass of water, a cheery face, or a hand to hold can and does change lives.

They needn't be done only by doctors too... My nurses were the people I was closest too in hospital. They, the receptionists and my social workers have been rocks in torrid waters for me countless times. The words Patch Adams, the world's most famous clown doctor said to me once rings true to this day - "Do you stop being a doctor once you leave the hospital?" Are good deeds and gestures limited to medical personnel? Could similar gestures on the outside help people just as much as in hospital?

All of this goes to show that no matter who you are you MUST take every opportunity to try and spread this cheer in the world. It's what makes all of this worthwhile. It's what makes your job a profession. It's why most of us got into this in the first place.


But this isn't the only solution.

It's just a job.


This great article goes into another way of dealing with burnout and dissatisfaction - dissociating from it all and realising it's just a job.

It's an idea that's frowned upon, to say the least, by most medicos. The idea that we do this to help others underlies everything we do. The Hippocratic Oath we take precludes such apathy and nonchalance. But as Dr Profeta argues, this approach leads to a near zero burnout rate in ED, which usually has attrition rates upwards of 50%. Sure, smiling and nodding when required helps, but it's not necessarily helpful in the big picture.When Profeta's son was diagnosed with leukaemia, he dropped everything, and even left his post in ED, to be there for him. 

Perhaps this is the best way to deal with it for some.

It's not easy to be there for people all the time.

It may well be the best way to deal with it overall... In a job where you have to face human suffering every single day, taking a step back may be the only way to cope.

But at the same time, beneath it all, we are all human. We can't help but care. And I'm sure Profeta himself would agree, when his son went through his ordeal, he would have been spared much suffering if he had a caring, empathetic doctor. One who would keep him company, talk to him at his lowest, and inspire him to keep going even when times were tough. One I was lucky enough to get myself. 

Sure, there are other things we can do. 

Learning to take breaks, and fostering healthy habits are other great measures we need to take. 

Talking about it openly, and sharing stories is one great measure that's already making waves. Top down changes and the acknowledgement of there being an issue is another. Australia's AMA is seeking to further this, and has also taken further steps to increasing dialogue between doctors and medical students to fix the toxic culture. One of the most important things, I believe, is to get students to ask eachother, "R U OK?" 3 simple words that have and will always save lives. If people can look out for eachother, and be frank about their shortcomings, perhaps then we'll have less doctors and future doctors suffer. 



One of many amazing stories shared on the Australian Medical Student's Association's Facebook page seeking to break down the stigma around mental health and get at risk students the help they need. I took part in this campaign too. My one's at the bottom. 


But whatever the measures, it's clear that something needs to be done. That talk needs to become action and that the most isolated among us need to be heard.

I for one am trying to do my part. I hope you do yours too. 

And for those thinking of doing medicine - I hope this doesn't scare you too much. 
It is an amazing profession - one where you can make an impact every single day of your life.

It is tough. 

It is grueling. 

But it's so worth it too. 







5 comments:

  1. Hi Nikhil, I love your blogs.

    And, for what it's worth, I don't hate med (most days) these days.
    It's not everyone's experience, but as you know, I found parts of med school excrutiating, and I was frequently exhausted.
    I'm still frequently exhausted, and I complain a lot, but for me, there's JUST Enough autonomy and just enough money (it's not a lot, btw, I delight in telling can drivers and random strangers what I earn) that it's better. I think it's the autonomy that's different.
    Because you have a little bit more control, and I know what's helpful for me.

    It was a long hard day: Christ knows I resent how late I wound up working today. There were too many things to do, and too many requests made of me, some of them inappropriate, and some impossible. I didn't do them all. What I like about being a paid employee is the ability to decide what is best or most important. I will chart a stat empirical dose, because I know I have spoken to pathology and will have better results to make a better decision tomorrow. I will spend 45 minutes documenting this patients behavior, but I will not give them a sedative or resite their Canulla while they are behaving like this, I have told them so, kindly. I will stay back to document that this patient needs an early breakfast then nbm. Those things are important.

    But the most important things are the ones you don't mind spending time on. "I'll take them, it's on my way" (it's never on my way). "Its very possible that you will need an extension of the dates specified by this medical certificate, (I think your boss sounds like an ass, and I think the reality of what you've been through hasn't hit you yet) team is happy to provide, page me on.... " And my personal favorite "I'm with a patient!" (Oh, my team weren't asked to see them, I just saw they were back and thought they could use a social visit"). And, as you say, I recently had the experience of keeping an understandably distressed pt in clinic for far too long, trying to sort something out. Eventually we both started doing our own work, while we were waiting, separately but together, and I saw that this was a little thing that helped the patient feel safe.

    There are bigger and littler things. The patients you follow. To whom you are meaningful, who are meaningful to you. For me, those are the hard ones, and being involved and available helps. It's hard to be there to bear the bad news, perhaps delivering it, or foreshadowing it. But I've found it easier to do it than not. What a tiny joy to be able to write " have clarified with team, pt and family: patient is terminal and for comfort measures only, they can eat and drink as tolerated for comfort. Remove Canulla, cease obs. Allow unrestricted visitors". Little comforts.

    Working is hard, but god there are good moments. Some are really good. Some are not good, but consist of me telling myself "I want to go home, but by documenting this incident, I help keep this patient and my colleagues safe and that is a good and important thing" until I believe it.

    It's gross. It's heartbreaking. It's a long road. But when it's good, it's really good.

    I have never charted some electrolyte at 7pm and thought "wow, I could be saving a life!". But I have sat with families in tears and thought, not "shit I hope I saved their life with my antibiotics and their kidneys survive to tell the take" but "I hope I've done something to make tonight a little more bearable for this family"

    Counting the little shit helps.

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    Replies
    1. Claire, your comments, as usual, are amazingly insightful and so eloquently put.
      I'm so glad someone like you is out there in the workforce. I know many many people are exactly like you - they do care and do do those little things that make a huge difference, and for people like you, I am eternally grateful. Indeed, I'm grateful for all doctors. We are truly in a blessed profession to be able to do all this and make a difference in peoples' lives. I know you are for sure. Don't ever question that!
      I hope that you doing this makes those bad days more bearable. I just hope you don't get to a point where you see too many bad days and not enough good ones. But if you ever are, or if you ever do, please do tell me and please know there are many people who love you and want you to be happy. And that you deserve happiness, just as much as anyone else.
      It's a brutal profession, caring for people. But it can be so rewarding too. Here's to more of the rewarding parts than not!

      Delete
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