Moral Commitments

Why did society appoint the title of 'Doctor' to medical practitioners? Some years ago I came across a book describing the meaning of the word 'Doctor' as 'Teacher', where patients were educated by practitioners about illness, how the medical world has come to understand illness and the possible remedies available. 

In the olden days, the relationship between doctor and patient was paternal. The doctor would simply instruct the patient how best to approach their illness and essentially make their management decisions. In today's era, where such a large of volume of information is available at the click of a mouse or tap on a touch screen, patients have become the central decision making body, along with their family and friends. If patients do not have the insight or autonomy to make informed decisions, a public body may be appointed to make decisions on their behalf. No doubt there are hundreds of pages of ethical discussions surrounding the concept of informed consent and decision-making on behalf of patients, and I would be beside myself if I thought for a moment I understood the depths of those discussions. 

However, what I have noticed is the lack of education that patients receive from their doctors. And to sit in a lecture and be taught that "psychoeducation is a fundamental component of a patient's therapy" as a senior medical student alarmed me. Students can get lost in all the dimensions of disease, their epidemiologies, risk factors, aetiological theories and the various management algorithms that are available in the large arsenal of pharmacotherapy and surgery. 

So then how are we to help our patients if we do not educate them? It is very interesting to interact with people from such a vast array of experiences, education and careers. To educate them about their illness is a privilege in itself. But patients continue to complain about the lack of education they receive, the counselling they long for and ultimately the respect they deserve. 

Ironically, doctors get frustrated with patients who walk into the clinics with 10 pages printed from Google saying that "Cranberry juice can effectively relieve symptoms of incontinence" and are inflamed when they are asked "but why doesn't this work?"

This brings me to something that happened at work last Sunday. It was quiet in the morning and little did I know the afternoon was going to be chaotic, but on I went with my morning with some tea and procrastination. The phone rang and on the other end was a patient who wanted to re-schedule their appointment. The study was for a CT Abdomen & Pelvis, which more often than not requires contrast (ie dye to highlight either the gut, or the blood vessels). The receptionist who scheduled her initial appointment told her about the oral fluids that would highlight her bowels, but did not mention the injection for the blood vessels. So when I explained that aspect of the study, Abigail was rightfully shocked. She calmed down after I answered some of her questions. At this point in the conversation, I was a radiographer and she knew nothing about my medical education. 

She decided to ask me "so why do I need this study?" 

Has your doctor explained why you're having this done?

"Well, I just moved up here and my friends recommended this GP who's apparently very thorough and I told her about my grandfather dying at 93 from bowel cancer and she decided to order a blood test. She called it a Ca 19.9, which was slightly elevated and then she did it again and it was even more elevated! She asked one of the other GPs and they recommended a colonoscopy but she thought we'd start with a CT scan."

I understand. 

"But why is she ordering a CT scan? What's that going to show?"

A CT scan is a 3D imaging tool that shows us the anatomy of your organs in a particular area, in this case your tummy, from the bottom of your chest down to the bottom end. Perhaps your doctor feels that this might show something that might explain the abnormal blood result.

"Okay. If this is elevated, does that mean that I have bowel cancer?"

Not necessarily. 

"But it's elevated. Why did my doctor order more tests?"

She may very well be thorough and wants to be aggressive to look for things because of your family's history of bowel cancer. 

"So that means if there is bowel cancer, the CT scan will pick it up?"

It may well pick it up, but there is also a reasonable chance that it might not.

"So what happens if the scan is normal?"

Well, it may be that she continues looking for the cause of your abnormal blood test.

"You mean a colonoscopy?"

Maybe. I'm not sure. 

"So if I don't have bowel cancer, why is this blood test abnormal?"

That's a good question. It could be that the blood test is slightly elevated, but have you ever had this blood test before?

"No."

Well how do you know it wasn't elevated 10 years ago?

"I don't."

Exactly. A pathology laboratory determines a normal range by getting thousands and thousands of results, applying all sorts of fancy statistics to them and look at what the most common numbers are in people that do not have illness. So it could be that you are the lucky one that has a slightly abnormal test but that's normal for you but outside the norm in the majority of people. Does that make sense?

"Yes. But it could also mean I'm the unlucky one walking around with bowel cancer at the age of 40." 

Maybe. But I'm sure the doctor asked you some questions about your bowel habits?

"Not really."

Okay. You do realise I have over-stepped my professional boundary about twenty minutes ago?

"I'm aware. But please help me... I'll keep the information to myself."

Have you experienced any change in your bowel habits?

“No, they are regular.”

Okay. Have you lost weight recently?

“Yes I have. I exercise regularly but 3 months ago I broke up with my partner and have recently taken up smoking. I also haven’t been eating the same since. I’ve lost about 6 kilos since we broke up.”

I understand. It could very well be that this weight loss could be due to the impact of the break up on your life. It could also be due to a sinister cause. Perhaps this is the reason why your doctor is ordering the CT scan.

“But I didn’t tell my doctor about the weight loss.”

Why not?

“She told me she had to go. I only spoke to her for about five minutes. But the first time I saw her it was for half an hour. She just had some personal things to do.”

"It won't be long"

This conversation went on for almost an hour, but by the end of it, Abigail was quite happy that her concerns were addressed. I was happy to talk to her given that work was very quiet that morning. I was also saddened by the fact this poor lady had been in such psychological distress about her abnormal blood test and the underlying reason for this was her doctor’s lack of commitment. The GP obviously had other [personal] commitments, which to some extent is understandable. If it is encroaching on your ability to see your patients and even worse, if it is denying you the ability to develop a therapeutic relationship, then I don’t see the point in having professional commitments. 

Saturdays

The last couple of weekends have been very intense for me in terms of work, driving and meeting people. Unfortunately it has come to the point where 'catching up' has become more for my concern for people's well-being rather than entertainment. Of course I do enjoy spending time with friends (more with some than others), however after a long day of driving and working, sometimes I just wish I didn't see anyone.

Yesterday I delivered the final lecture in the Radiology lecture series I have presented to the first year medical students. I'm hoping it was well-received and most of them seemed interested. I was able to reflect on the lecture this morning on my way to work with what limited attention span I have when I'm driving and it occurred to me how oblivious medical students in pre-clinical years can potentially be. To most of them, it is mostly about lectures, learning objectives and textbooks; despite the emphasis that patients are in fact the most important component of medical education. There are exceptions to the rule and I definitely was not one of them in my pre-clinical years.

Saturday for the last few weeks has been the busiest day of the week - I do almost 2-3 hours of driving, meet a few people and seldom make it home for dinner. But when I talk to my good friends, Saturday is a day to sleep in, enjoy a hearty and hot breakfast with loved ones and think about things such as the weather, music and sport. Saturday is for going out, enjoying a few drinks with friends and sharing laughs over some food. It's also for clubbing, dancing and meeting new people for the curious.

But for me, Saturday is about work, doing favours for friends and family, occasionally eating. I do spend time with friends and family, though sometimes I don't want to. I would love to sleep in and not think about what to do, who to meet and what to prepare. I want to wash my car, pick out all the leaves from under the bonnet while listening to music. Sometimes, I don't want to communicate with anybody. I just want to listen to ambient noise.

When did Saturdays get so busy? It all started in year 4, when my parents decided to send me to Saturday school for developing my language skills in Turkish. So I only was able to sleep in on Sunday mornings, but most of the time my parents would wake me early to have a family breakfast (not that I'm complaining - it's awesome food). That clarified a lot for me - Saturday has been forged in my head to be a day of work or study, unlike most of my friends in school who enjoyed the sleep ins, soccer games and Centennial park. After primary school, it was Saturday high school, after that came work at Harvey Norman and Math Tuition, after that came Radiography.

What about the school holidays? Good question. I spent most of my time catching up with movies, games and the occasional game of basketball with the local kids. What about sleep? Even now, I can't sleep in unless I force myself to stay up, which is useless because I still end up sleeping the average 5-6 hours a day.

I stay up late because I just want time by myself to do the things I want to do, such as play a video game, blog or watch something. I can only do this at inappropriate times of night because that's when people are fast asleep or have established that at such times it is socially unusual to contact people. It's my rebellious way of saying "fuck you Saturday, I'll still end up having time to myself, no matter what I do during the day." Though it is becoming quite old-fashioned and immature, I am still gripped with the decision despite the exhaustion.

As much as I would love Saturday to be a day off and to establish some level of sleep hygiene, it seems that such a wish is out of reach for now, and may just be for decades.

But then again, I'm not the kind of person to sit still. So if I did ever take time off, I would find a reason to wake up early and do something to make myself useful, to use the privilege of having a day to spare wisely.

Please enjoy your weekends and rest assured. As much as I am complaining, I too enjoy my Saturdays.

Unlocked

Internalisation is a process by which genes are activated to change polymorphisms, facilitating the displacement of receptors, channels or substances from the surface to the intracellular space. I probably didn't use the correct terminology to explain the above appropriately enough, but I'm sure you have understood or are familiar, to some extent, with this biological phenomenon.

Our particular subpopulation is prone to emotional and psychological trauma. It might be foolish of me to say, but we often forget that patients are sick; patients need our help. Last week Dr. KF introduced us to Matthew, one of her favourite patients. He was a man who looked 65, but was actually 51. His big, white beard seemed well-maintained for a man who was homeless, had a longneck beer in one pocket and Tally-Ho cigarette paper in the other. His clothes were torn and faded.

Matthew sat with us for over an hour, talking about his experiences in prison (over 5 years for different offences), told us about his relationships, children; but mostly he told us about his addiction to heroin. This man was well read, mild mannered and had a cognition that was intact. There was a significant mismatch between his physical appearance and behaviour; his colloquial language and intellectual descriptions. He took us through how he had organised to continue his addiction through financial means, manipulation of prescriptions and many other facets of his life.

We patiently sat there, trying to make sense of the history and piece his story together but he was a very good communicator. He went from story to story, they all seemed related and he would use one story to explain another story, which clarified another. And we did the best we could to organise the information in order to process it, well before even thinking about presenting it to a senior clinician.

I very much appreciated him volunteering his time to talk to us about his experience. It was clear to me that Matthew was a good person, a down to earth, wise human being who had been through much more than he bargained for. He was introduced to alcohol at the age of 6 by his parents and first started experimenting with illicit drugs at the age of 14, in between reading about Ancient Greece and the components of a Constitutional Monarchy. So then why the jail terms? Why the homelessness?

Being under the influence of any drug distorts the senses. They can create are called positive symptoms (ie experiencing things that are normally absent) and or negative symptoms (ie being deficient in things that are normally present). Matthew had committed crimes of theft a number of times while being "high" on heroin or speed and well, they added up. But he never meant to steal anything. There are times he did consciously to support his addiction and maintain basic human needs such as food and drink (although beer does not constitute a human need).

But what of his health? Does he look like a 50-year-old man? What of his past medical history? Did we ask him about his family history? If this gentleman is an injecting drug user, what are his medical risks? If he uses prescription narcotics routinely, does he experience the side effects? If so, how does he manage them?


Our supervisor drilled us, painting a portrait of the patient's history on the walls with our brain matter. Matthew admitted to having two heart attacks in the past. No follow-up, no regular doctor. But why? If a person had a critical illness, wouldn't they feel the need to present to the emergency department if not their doctor, or any doctor?

Imagine you're the emergency doctor and an middle-aged man presents to you complaining of chest pain for a couple of hours with shortness of breath. After you take a thorough history of his presenting illness, past medical history and all the other biological stuff, you get to the drug and alcohol history and he admits to using heroin regularly for the past 36 years. Are you going to give this man morphine for his chest pain?


Given the way Dr. KF asked the question, the answer was obvious. But the truth is, other people out there, qualified practitioners, do not see it that way. This person could very well be trying to manipulate the system to obtain narcotics to maintain his "high". Such people are dismissed in the emergency room, made to wait hours on end without pain relief; and this was all in exchange for honesty and trust in the medical practitioner considering their complaints.

Can homeless people not have strokes? Can a heroin addict not have chest pain? Who are we to judge them?

It's a disgrace. We ignore these people, avoid contact with them and change direction if we see them on the footpaths. I wanted to help. I didn't want to judge, discriminate, or dismiss. And I hope I never do.

Initially I started writing this entry because I wanted to talk about internalisation. It is fascinating because I do it consciously all the time. I look at my life and the things that should concern me on a daily basis; sometimes I stare at the world around me caving in with the demands I have set up for myself. Then I leave all of that at the automatic doors.

I have been unable to do this in Psychiatry as of yet. As in the movie Inception, we all have secrets and they are locked away in safes, hidden deep in the midst of our thoughts, clouded and distorted by surreal defence mechanisms.

There is a lock that obstructs access to these secrets, which could otherwise be discovered through a door. It is as symbolic as it is literal. We interact with each other (friends, patients, etc) and try to make sense of who they are, their hobbies, principles and morals; perhaps we dig further and find out about their family, religion, country of origin. Over time, we may be allowed to dissect deeper until to us a door is revealed. And there is a lock. Each individual who has had the privilege of being exposed to this door was also given a key unique to them. This unique key exposes to the listener, friend (and perhaps healer) to the mysteries of an individual's vulnerability that [the patient] has explicitly allowed.

Such an intimacy might take years to build. Decades to maintain. Seconds to shatter.

Psychiatry demands instant assessment of the individual. For me, this has been an unnatural experience. I am meant to start my 'examination', or perhaps analysis, from the moment I have obtained consent for the discussion to take place. I must assess their general appearance, mood, speech, thoughts and cognition; and much more. Such things the non-psychiatric clinician takes for granted. It never occurred to me to consider these factors in assessing a person's well-being and I definitely didn't think that such assessments would unlock the door to my own darkness.

So here I am, on my blog, slowly spilling out the stories one at a time.

I have been feeling down most of the day, with intermittent bursts of happiness, easily reversed. So fragile. I didn't go into the Addiction Medicine department in the guise of a 'day off for study and rest' but the truth is, I felt weak. I didn't want to face the patients with the tragic stories for fear that my own insignificant demons in comparison would be revealed in some subtle way to reflect my weakness.

My door is slowly being revealed to those around me, but also to me and I am so afraid of what I might find if I open that door myself. I can only avoid what kind of fear I would be feeling if other people could access it. And there's the catch. I'm in Psychiatry right now, surrounded by people that can analyse my appearance, speech, cognition, thoughts and every other component we are taught to assess in each patient.

So I stay quiet, in the background, occasionally suggesting this or that, trying my utmost not to dig myself a hole.

It's the second week and I really am not sure if I am emotionally ready to face what awaits me tomorrow.

As a person with Surgery in mind as the specialty of choice, I am finding Psychiatry quite frightening and I am beginning to see why surgeons are able to avoid it, ignore it and dismiss it at the times they are supposed to address it in themselves, in their friends, family and tragically, even their patients.

Before 2230

It was my second day in Addiction Medicine and I started settling in after getting to know some of the patients. The typical 'medical student' day in this department is from 0900 to about 1400, but I make a point to stay back as long as I can, to do what I can to help. Thankfully, most of us are doing the same thing.

My wristwatch read 1700 and I thought it was about time to go home and head over to the gym. I have been neglecting my physical health for a couple of months due to exam preparation and a whole lot of procrastination. The phone buzzed and walked over to pick it up. It was Dr. KF, my mentor and now my supervisor in this sub-specialty rotation. 

I was hoping you could accompany the intern tonight on his evening shift in the hospital? He only just found out he's working and hasn't had much to eat. It would be great if you could give him a hand if you're not busy.

I'll be there in 5 minutes. 

Thanks so much.

Dr. KF bought the intern and I some dinner before the shift started. As expected, the pager started piercing the air, prompting us to head over to the wards. We ate quickly and off we went. 

Which wards are we looking after tonight?

Surgical wards and also the medical assessment unit.

The Medical Assessment Unit (MAU) is the place where the majority of the geriatric patients go for assessment prior to admission to hospital. So the patients tend to have a very complex medical presentation with multiple problems as well as Not For Resuscitation (NFR) orders. The families tend to be involved in decision making, if they don't make the decisions on behalf of the patients altogether. 

The first consultation was out of the ordinary - the paediatric ward for some analgesia prescriptions. That didn't take long and we soon made ourselves known to the nurses in MAU and the surgical wards. It wasn't as chaotic as we anticipated and so we took our time taking bloods, inserting cannulas. There was the odd scare - a few hypotensive patients in the surgical ward gave us a fright but after some observation, they were fine.

So far, so good. 


At about 2100 things started to get hectic. The intensity of calls for cannulations, bloods and medication reviews spiked and at this point the intern and I were on separate wards. I can't say I was comfortable with the frequent misunderstanding that I was a doctor and not a medical student. I'm sure the nurses did get rather annoyed with being corrected constantly and in their eyes, if we were wearing shirts, ties and holding a stethoscope, we were no different. Appearances can definitely be deceiving.

It was almost 2200 and we were about to make our way over to the common meeting room where the hand-overs were done. I had the intern's pager and he was at the other end of the surgical ward. I was just talking to a patient about inserting a cannula and the pager went off.

E2 medical student. Somebody paged?


Yes, I'm calling from MAU. Bed 1 has stopped breathing.

And that's all I heard. I put the phone down and power walked toward the intern.

We have a MET Call. 


Fuck. Let's move!


MET referred to the Medical Emergency Team and they are composed of an anaesthesiologist, intensivie care physician, nurses and other team members. We both ran down the surgical ward, waking most if not all patients with our not-for-sprinting shoes and the nurses on the wards weren't phased much; they understood the significance of our haste.

When we arrived outside Bed 1, all the curtains were drawn and the lights were off. MET was obviously not called and I hadn't let the nurse explain that the patient was NFR.

The intern looked at me. What are the components of the clinical assessment to declare a patient dead?


I drew a blank, but quickly composed myself. Dilated and unresponsive pupils. No heart sounds. No breath sounds. No response of any kind to painful stimuli.

Good. We have to elicit them.

After spending a few minutes looking for a pen-light, we went to examine the patient.

He was pale and stiff; his face and neck turned to the right with his mouth open and eyes partially closed. We called his name and there was no response. We shook his shoulder and he did not startle. The intern looked at me as I handed him my stethoscope. He confirmed the absence of heart and breath sounds. Then he pinched the patient's chest, then his eye-brow... there was no response. The pen-light partially lit the room and we looked at both his pupils, completely dilated and they were not responsive to light in any way.

He's gone.

It was the second shell of a patient I had seen. Quiet, calm and absent. I had trouble putting my thoughts together and thought it would be best to just stay silent and only speak when spoken to.

I got home and shed some tears - I wasn't expecting this, but then again, that's my mistake. We are in a hospital. We deal with death everyday. The intern seemed to have no problems with it. It wasn't long before he was talking about the weekend, some facebook competition, karaoke the night before and which girls he was attracted to. Thankfully he was talking to another intern and so, I could tune out from their conversation.

This wasn't the way I was expecting to start Psychiatry, but one way or another, I end up getting pulled into some task, somewhere. And I definitely do appreciate it. Everything is a learning experience and no two patients are the same.

The next day I was tempted to go and see some of the patients we saw over the evening, but decided against it.

I am grateful for this week to be over. We have a lecture or two in the late afternoon and then I am free to relax throughout the night. Some time to myself and distractions with books and lectures is what I probably need.

Seeing some of my friends also made me happy. I look forward to keeping in touch with more of them now that I've returned to the student accommodation. 

Intima

After the very short break, I started back at the hospital, assigned to the specialty I knew very little about. Colleagues had told me it was radically different than 'traditional' medicine and there was little I could do to prepare myself.

Some of my close colleagues didn't think much of Psychiatry, but I knew I had to take it seriously. The patients are vulnerable, and perhaps I am too. It seems to me the art of medicine can truly be elicited here as nothing is more important than establishing rapport and trust in an atmosphere riddled with vulnerability, distrust, doubt and much more. There are few organic (i.e. identifiable) causes of a patient's abnormalities and thus, clinical examination, laboratory investigation and radiological assessment are barely helpful except to rule out obvious, yet uncommon, identifiable causes of a patient's illness. Essentially, the only tool that is useful to organise and understand a patient's complaints is the history (i.e. interview).

I am currently assigned to the Department of Addiction Medicine, which is a subspecialty in its own right as the sub-population is highly unique. These are people banished from society due to their addictions and are incredibly distraught by previous experiences in their lives. Their sensitivity is striking and they pick up on the smallest notions of judgment, condescension and any hint of "I'm better than you, so let me help you." Not that I'm like that at all, but one has to be very conscious of their reactions and responses to the details these patients reveal. We must be empathic in moderation - going overboard may disrupt the rapport and showing little will destroy what structural support the initial impression a clinician gave the patient. This is a critical opportunity for us to practice people's skills and I'm sure we could all use a little of that.

The patients were somewhat uncomfortable and apprehensive. When I took notes, some of them were very concerned about what I was going to do with these notes and I found it difficult to explain that this information may be useful for their care. I'm not sure how they felt about that, but it was clear they weren't comfortable. I must get to a point where I can recall the majority of the history from memory, but that will take a very long time.

Growing up in the suburbs I did, drinking was a normal part of the playground. Young teenagers and their parents drank in the morning, afternoon and evening; sometimes well into the night. When there was no alcohol to buy, they resorted to drinking methylated spirits. Playing basketball around these people made me uncomfortable and the frequent bullying and glass bottle-throwing was not a nice gesture either. So I hated them - these people who drank until they couldn't stand, feeding their children and encouraging other children to join them. My hatred of alcohol use was amplified when I was old enough to realise that my father was a drinker. He had his nights of binge drinking, but what bothered me the most was the fighting. Then the late night self-talk he mumbled to himself, mostly profanity and the slamming of the china as he washed the dishes at peculiar hours. I enjoyed the odd drink of alcohol, but not to the extent that I was so drunk I was saying whatever came to mind and doing whatever I pleased.

High school exposed me to drug dealing in the bathrooms, marijuana use by my close friends and even cocaine in the final years. I didn't take drugs, but it was certainly popular. If I knew my friends better, I could have also known about their obsessive use of anti-depressants. And these memories have resurfaced in the last few days. Well, I guess that's slightly inaccurate: my father still drinks about 1-2 bottles of wine per night, every night for years. Every time I stay with my parents, I get angry and shut myself in my room, watching movies on my own or playing computer games until I was tired enough to sleep quickly when I went to bed.

I didn't like what was happening around me and it was easy for me to judge people. Thankfully I didn't have these thoughts and feelings when I started the rotation, and they haven't surfaced in the clinical setting as of yet. Every patient I have spoken to has mentioned sexual, physical, verbal or psychological abuse by either their spouses, children, parents or siblings so far. The very people that were supposed to be supporting them were the people destroying them.

Interestingly, all the patients I spoke to this week were self-admitted. I admired their courage and strength. They knew they couldn't survive any longer out in the world of pain, damage and abuse. At the same time, they wanted to get over the addictions they developed to numb the scarring and agony. Some of these people were disadvantaged since they were born, others had significant events that changed the course of their lives.

We as students, clinicians and professionals must be very careful to help these people through such a very delicate time in their lives and I hope we are able to make them feel safe, comfortable and eventually, create an atmosphere where they can speak to us about the things they like.

Our past will re-surface and we must be careful to maintain our own composure while remembering that it is the patient that is the strong one - they confessed, admitted and presented for help. We're still just coping within the barbed-wires of defences we have set up in our own minds.