Travel

After scraping through my Psychiatry exams, I was able to take a breath of fresh air. My muscles were finally able to relax and I could slouch in a lazy sort of way. Third year is now behind me and I can focus on the challenges of 2012... But not before heading out of the country for my elective term.

I'm not sure how electives work in other medical schools. Our elective rotation is at the beginning of final year. I chose to organise my own like most other colleagues and decided to go to the hospital my parents met, where I was born.

Istanbul has been quite an experience so far. Traveling is certainly different and seeing another country's people (even if I'm one of them) is always an eye-opener. The culture is so different, so vivid.

The history is vast, stretching from early Christianity through multiple Empires and resting in the hands of the Turks. Walking down the cobblestone streets and hearing the sounds of the Imam calling the people to pray is just something else. There is a sense of affection in the atmosphere, where you can approach anybody with any question and they will greet you with a sense of respect I barely experience back at home.

Witnessing courtesy upon public transport was magic. Watching the young make room for the elderly, offering them a seat or a hand was amazing. One lady entered the bus via the backdoor with a large suitcase because it was very crowded. She struggled to get her bus ticket out of her purse and then I saw the people pass her ticket from one to another up to the bus driver and back. Such a commonplace occurrence here, unheard of back in Sydney.

Aside from sight-seeing, I've been able to concentrate on absolutely nothing. Just looking around, breathing in the cold air of the Northern Hemisphere, taking in the scent of the soil and occasionally tuning into some conversation.

People start asking what it is you want to specialise in once they realise you're in the final stages of a medical program and I've said "general surgery" so many times that I'm not sure if it's really what I want to do or what I just keep telling people what I want to do. I didn't get as much out of my surgical rotation as I'd wanted and I'm taking advantage of the elective term to be sure general surgery is the way to go.

I speak to colleagues about their career choices and some of them are so certain in their decisions that it baffles me; I'm not sure if I should be happy or feel sorry for them. I've already seen some colleagues crumble at the very hint of second-guessing their career choice and it saddens me to see these potentially amazing doctors devote to a certain field so blindly. The irony is in the simple fact that it's not their fault.

Somewhere under here is a medical student
experiencing role confusion.

We've all experienced some degree of role confusion in a hospital. A patient or their relatives might've mistaken us for a doctor, for example. Some of us have also felt the pressure of role confusion, when a nurse might've asked us to write up a medication in a patient's chart knowing the doctors were long gone. We eventually become part of a team and commonly the work is so intense, our role as an observer is violently crushed beneath the boulders of responsibility. Naturally, we believe that we have a reasonably good idea of what a team's specialty is about given our participation and our career choice may largely be determined by the level of responsibility given. Also, not mentioning how nice a team was and how that influences a person's decision in career would be criminal.

I find myself in this state of relaxation and it has allowed me to feel my insight into the field of surgery and how limited it may be. As a medical student, it's easy for me to criticise the work of other doctors and healthcare professionals without feeling the pressures of time, a pager and several registrars on my back and the handful of consultants on theirs. Once I think of all this in a non-stressed state, the accumulation of doubt about my career choice doesn't take long.

So the question that many non-medical friends ask remains: Why Surgery? And maybe I should take a shot at answering it:

For starters, it allows me to offer very intimate care. In my mind, accessing the workings of the body with the understanding of anatomy is as close as you can get to any patient. I believe obtaining consent from someone about dissecting their tissue planes is not only professional and ethically crucial, but also an important part of the healing process. Patients often present to surgeons when all other medical efforts have failed, meaning that in most circumstances surgeons offer hope and care in time of greatest need. I want to offer such help to people.

Within me there is anger toward the next generation of doctors. People are enthralled in hobbies, television shows and many other things that hibernate the active mind. An alarming proportion of these have university degrees and professional responsibility that require more than a person's ordinary attention. Hospital administrators and the justice system have put in place laws which literally strip doctors of their licenses due to misconduct, unprofessional behaviour and negligence. No no, the fact they exist doesn't disgust me... the fact they're necessary does. It's obvious these 'practices' have become so common the entire cohort must be forced to recognise them. The essence of all this? The moral code that once would've stopped medical practitioners has now eroded into the sandstone of standards. Therefore, society's examples of morality now lay hesitant not because it's wrong, but because they can be prosecuted.

Also, what is this bullshit about working hours? When one loses a credit card, there's a 24-hour phone line to call so your limit doesn't get maxed out in 5 minutes. When shit hits the fan because the plumbing's blocked, there's a 24-hour plumbing service so you don't have to take a week of annual leave cleaning shit off your business shirts. If you're hungry after a late night, McDonald's is open 24 hours a day, seven days a week. So what? Doctors are only available 9am to 5pm Monday to Friday? Why? Because after all the education, training and research, there are more important things deserving attention like Bondi beach, Gucci and Mercedes Benz? Get serious.

Patients need our help and if we are to be their go-to general practitioners or specialists one day, we must make ourselves available to them when they need us, not when there's a spot in our dairies. Doctors are public servants. Yes yes, our children, spouses, parents, siblings are important too; but we took on a moral oath when we decided to pursue this... or did we?

As a surgeon, one must be available at all hours of the day for long periods of time because they are required in dire need. You can't tell a patient with a knife through his/her abdomen that they'll have to wait until you finish your 18 holes. Same goes for patients dying of cancer. Yes, it can take weeks for a tumour to kill someone, and that may justify taking your time... but if you were living with something growing inside trying to kill you, every minute of that experience would be horrifying. Other specialties are more forgiving and it's the main reason people abandon their surgical aspirations. Of course, one must be realistic - there are waiting lists and patients must be prioritised, tragically sometimes according to their socioeconomic status.

But someone has to do all this. I want to be one of those people. I want to offer people care when they need it, not when I feel like it. And yes, I want to be taken seriously and not appear too stupid in front of my colleagues and patients... hence, being a Physician is out (because I don't think I'm smart enough). Psychiatry is emotionally taxing and whoever thinks it's an easy specialty seriously needs revision; perhaps even ECT.

Here I am, eager to be useful, trying to help and I'm optimistic about this elective term in general surgery. Our Dean of Medicine once told us about some research done on medical students suggesting the elective term as being the most career-changing rotation in our clinical years. It has gravity. There are reasons why I want to do surgery, but also reasons why it may not be such a good idea. I must continue to think it through carefully. Slowly but surely.

A Day in Psychiatry

Psychiatry was a roller coaster ride for me. It went up, down, side-to-side and it was enjoyable for a while. I was on this ride for eight weeks and I'm starting to ask myself "Was this real? Or was it just a ride?" Seeing patients with such disabling, dignity-stripping illness crippled me and I had trouble composing myself on a day to day basis. I looked for ways out - I wanted to leave early, take days off and try what I could to avoid the ward.

But Dr. BB, my supervising Psychiatrist, was adamant that I stay for all activities and help him in any way I could. I really enjoyed working with him and watching him speak to patients. There was something about his mannerism and passivity that was therapeutic even if I wasn't the one sharing my worries and stressors. He emphasised principles that few consultants paid attention to, such as introducing oneself as one the caring doctors and asking "do you have any questions for me?" It was these qualities that enraged me when he asked me to attend the ward on the Friday after the exam was over... but it was also the same qualities that propelled me to come in. 

One afternoon, I was milliseconds away from a total public breakdown. On morning handover, we listened to the supervising night nurse explain the inpatients' behaviours over the last twelve hours or so. The tone was very "us against them" and even more "I've heard all this before. What's for breakfast?" Dr. BB asked me to attend the Electro-Convulsive Therapy (ECT) session that morning. He said he would join us (the students) later and Dr. ZN, one of the unaccredited Psychiatry registrars, was in charge of the session.

J, G & I headed over to the outpatient's clinic, where they had a room with an old bed beside an even older set of anaesthetic monitors leaning on antique exercise equipment that was gathering dust since the hospital declared them unsafe for patients. The very atmosphere made it clear the hospital wanted to forget patients undergoing ECT as much as they did the lawsuits that were a consequence of faulty exercise equipment. 

Dr. ZN was an overseas doctor who passed the admitting exams in Australia. I had already spent a couple of weeks with him in C-L Psychiatry earlier in the term and he seemed nice enough. However, it became quite clear the admitting exams did not test empathy or basic common sense. 

Ashley, the first patient on the list, was wheeled in. The anaesthetic team was there, waiting for him. He was a young man with schizophrenia with such profound negative symptoms that the Psychiatrist believed he would benefit from ECT. Dr. ZN was with us by the corner of the old bed explaining the differences in parameters with the ECT settings, why one might be better than the other and the idea behind it. This all happened so quickly that before we knew it, Ashley's face was but a few centimetres away from our backsides. We didn't even notice before the anaesthetic nurse said "watch your step" as he plugged the ECG leads in. It was then we realised we were literally rubbing shoulders with each other and that we should probably give the poor man space. 

Dr. ZN couldn't care less. He proceeded to explain the voltage, amperes and hertz he was selecting as poor Ashley's head was beside Dr. ZN's waist. I could feel the rage building up inside me. The disgust really started when he pulled out a couple of alcohol wipes and proceeded to hold Ashley's head and wipe it down as if he were cleaning a mud stain from the top of a leather boot. I was surprised Ashley stood still. He didn't explain what he was doing, why he was doing it and Ashley didn't even know his name. 

As Ashley was wheeled out after his medically-induced seizure, Dr. ZN continued to explain his waveform and why it was a 'good shock'. 

Elaine was our second and last patient for the morning. She was wheeled in by one of the mental health nurses as she cried her eyes out, begging all of us not to proceed. Unfortunately it wasn't up to her, as Dr. BB presented her situation to the medical tribunal, who agreed with involuntary ECT for her melancholic depression to, I guess, shock her back to reality. 

My blood pressure really started soaring when Dr. ZN continued to explain the waveforms, "alpha waves bla bla bla. Beta waves bla bla bla" while Elaine was crying her eyes out. Her depression started after her husband had a disabling stroke and she was left with all the responsibilities around the house. So she was forced to retire and proceeded to be his full time carer for a solid two months until she literally felt inadequate, incompetent and hopeless. Eventually, her feelings of inadequacy lead her to lose touch with reality. 

I was praying someone would shut Dr. ZN up before I broke his neck, because at that point I didn't know what was holding me back. Finally, the mental health nurse approached him and said "excuse me... I hate to be a pain in the ass but your patient is really unwell. Maybe you should go over there?" he smiled sarcastically and reluctantly agreed. 

Then G, one of my colleagues, proceeded to explain how he met Elaine and thought the point where she was struggling in bed while they were sedating her was a good time to explain her history. I felt J was also quite disturbed by what happened and we both shot G a look, and he didn't understand. 

Could you shut the fuck up? 

"What? I'm trying to explain her case to you!"

It's really not a good time.

"Yeah, G, seriously. Just shut up."

G, baffled, walked away from us and sat down to read Elaine's notes. 

At that point I needed to leave the room. I was holding my tears back and then Dr. ZN looked at me from across the room and said, "You look a little detached!" with a big smile on his face. That was when I walked out of the room. 

I locked myself in the bathroom and I was either going to break the mirror, cry, pass out or wash my face. So I did the most appropriate of those choices. After drying my face with some paper towels, I walked outside to find Dr. BB. He saw me and it wouldn't take a Psychiatrist very long to work out how I felt - my face usually does express my feelings quite well. 

He tried to pull me aside but I said I wasn't comfortable talking about anything there and then. He agreed, and said that we'd see a few patients and then we'd have a short meeting. 

J & I went with Dr. BB to the emergency department where we had a call from one of the doctors working in Psychiatry (a Career Medical Officer - someone who doesn't specialise but works their career in one speciality) to review a patient he was asked to see. He described Rowena as having anti-social personality traits and he wasn't keen on admitting her to hospital. After a few minutes of chatting to her, it was clear she had grandiose delusions, pressured speech and flight of ideas. Yes, Rowena might have had anti-social traits, but more importantly, she was really unwell.

Dr. BB asked the CMO to sedate the patient and admit her involuntarily into the mental health ward. When we went back to the ward to see more patients, Rowena was brought in by security personnel with no sedation, trying to wrestle herself free. We were both baffled. Why wasn't sedation given? Patients in mania are usually quite distressed and for the sake of harm-minimisation, this lady needed medications to calm her down.

It was a hectic morning and it felt as though it couldn't get any worse. Luckily, it didn't.

I ended up with Dr. BB in his academic office to present a case to him and to get feedback from him regarding my rotation. One could always present cases better, but I felt relieved that he passed me - he's a hard examiner... even if it was a practice run.

He then asked me what happened in the morning. I got worked up and angry about how patients were treated by Dr. ZN. It felt like I was throwing the words at him. By the end of it, Dr. BB was shaking his head in disgust.

I always tell junior staff to introduce themselves, be polite and respectful. They just don't seem to want to. There's not much else I can do other than to tell them. 


"But you're a consultant. Why don't they listen to you?"

I don't know. It's more prevalent among our overseas colleagues. 


"Perhaps it's because your feedback doesn't hold the gravity with them as it does with us"

Could be. 


There was a short moment of pause before we exchanged a smile.

"How do you cope with the things you see everyday?"

Mostly by speaking to other consultants and with weekly debriefs with the head of department. It's very important to share your encounters and thoughts on clinical situations with senior colleagues. 


"I'm having a lot of trouble seeing the patients in Psychiatry so far."

*Pause*

I really think that if you don't share what you see, you will lose touch with reality.

It felt like a bomb hit the building. "So what? People become psychotic?"

I do think so. You surround yourself with patients who have delusions, hallucinations; symptoms and signs that convey their reality is distorted. Eventually, anyone would find it difficult to separate all the stories from reality. It's very difficult to stay objective, particularly in Psychiatry.

We spoke a little longer to debrief but I could've stayed in there for an hour. But the bottom line was drawn well before I walked out of the room.

There is always a chance our reality will become distorted.

So I may very well still be riding on a roller coaster... and that may be real. 

Insight

We often forget how traumatising it is for patients experiencing their journey in healthcare. We are part of the hospital system; we breathe it, feel it and keep it alive.

Sometimes I daydream about a hospital in itself being a myriad of organ systems; a patient micromanaged by an overwhelming power (administration) in terms of providing life support (funds, employees) and this delivered through transporter proteins (Medical Teams), which release transcellular messages (investigations, management plans) with paracrine function to other local cells (Healthcare Professionals). Through this extensive, complex process, one reaches cells that are dysfunctional (Patients) and aim to reverse or control the damage (Disease) in the hope of restoring their function in the role of the whole (Community).

It is not uncommon for medical professionals to go about their everyday work and yet feel detached. Both as a subconscious coping mechanism and as a way of minimising their workload. And through these barriers, we set up not only thick skin resistant to the everyday tragedies we encounter, but also distort our senses: re-setting the "normal" range such that certain news that was considered significant (example 1: you need your gallbladder removed), life-altering (example 2: we need to remove your breast and most of your armpit to catch this cancer) and terrifying (example 3: there's only one solution: we remove your rectum, anus, vagina and bladder. It's the only way to increase your life expectancy) have now become benign, mild and moderate.

And the process is progressive; continuous such that the normality is continuously re-set as clinical experience lengthens and our insight deepens. This brings me to the situation that provoked these thoughts within me.

Matthew, a 28-year-old gentleman, was brought into the Emergency Department by Police under Section 22 (i.e. as an involuntary patient because he was considered mentally disordered). The reason he was brought in with his wrists clamped together with cold steel was a high-speed chase. We weren't told why Matthew was running, or what preceded the hot pursuit. But we did know we needed to see whether the police were correct about his mental state.

That's about all I knew about Matthew just before the nurse mumbled Bipolar Disorder at handover. The clinical picture was a little clearer now; he must've been manic. At that point, it was time to meet him with the Psychiatry registrar.

He was very agitated about being in the mental health ward. I'm being held against my will. Why can't you understand this place is not the best location for my recovery? Why can't you understand? What's your problem? Why are you looking at my hands? You keep getting distracted!


It escalated for a short time and I was sure that Matthew was going to get up and start throwing chairs around the ward, but luckily he didn't; another patient not too far away already volunteered his attempt at sharing a psychotic breakdown and successfully did with four security personnel and a nurse. After a few weeks in this ward, such events seemed not-so-dramatic.

I couldn't help it... I had to ask the registrar. Why did you keep looking at his hands?


"Because I was afraid he was going to get physical. Also, he had complained about upper limb weakness and paraesthesia earlier today. I was grossly assessing his movements. Seemed quite normal to me. What do you think?"

Uh.. I don't know.


The registrar decided to see Matthew a few hours later with the consultant, along with his family. I could sense that he was very restless and agitated, but not in a 'mentally disordered' way. He seemed rational and as the Psychiatrists say, "no formal thought disorder".

Matthew's parents and younger sister attended the meeting to discuss the issues around his admission into the mental health team. Apparently for the past few weeks, Matthew had been demanding his family sit and listen to his teachings about computer specifications, why they should purchase electronic goods with highly specific and elaborate criteria. It got to the point of happening every day, for at least several hours.

What do people do when they get home from work? They walk through the front door, take their shoes and socks off, get into their comfort zone and chill. Well, Matthew's family wasn't allowed to do any of that. They had to walk through the door and listen to his teachings. Luckily he had a job as a night-filler at the local supermarket and the family had some hours of peace late at night, which they used happily to rest and recover.

They wanted Matthew to continue staying in the mental health ward involuntarily until his agitation and from what we understood clinically, his mania, subsided. Dr. BB agreed and we asked Matthew to join us to discuss what we thought. The tricky part was to ensure Dr. BB made clear it was his decision to keep Matthew in the ward, not his family's.

Dr. BB - I don't think it is safe for you to leave just yet, Matthew. 


Matthew - Why? I don't see any reason for me to stay. This place is destructive. You're holding me against my will. How could you possibly believe this place is doing anybody any good? You can't smoke, you can't socialise with the other people. There's nothing to read, no access to the internet or phone.

Dr. BB - What would you like to do?


Matthew - I would like to go home where I can smoke, spend time with my dogs and cook some dinner for my family. I want to be able to do the things I normally do to lower my stress. But you can't do that here.

Dr. BB - What can't you do?


Matthew - You can't smoke, for starters.

Dr. BB - We have nicotine patches. I would be happy to organise them for you during your stay here.


Matthew - Mate you know better than me... There are twenty addictive substances in a cigarette. Nicotine patches replace nicotine, but what about the other nineteen addictive chemicals? Do you have patches for them too?

*Silence*

Matthew - This is damaging to me. I don't want to be here. I'm being held against my will. How do you think this environment is healing? There's nothing healing about it. The people are really unwell, the nurses don't give a shit and it takes half a day to see a doctor about anything. It's no different than incarceration.

Dr. BB - I understand. There's nothing I would want more for you than to let you go and enjoy everything you normally do. But -

Matthew - What about my job? I just signed a contract obliging me to work full-time for next twelve months. How can I call my boss? How can I keep this job if I just got this contract and I'm asking for leave? Would they let you do that here?

*Silence*

Dr. BB - I think it is important you stay here for the rest of the week and then we can review you. Once I'm convinced that you're better and your agitation has settled, we can think about granting you some leave. 


At this point tears started trickling down Matthew's face. He got up and stormed out of the room.

I couldn't help but feel sorry for him. Although he was mentally disordered to some extent according to the team, he had arguments that were hard to disagree with. How can cigarette addicts control their mood, agitation and attitude well without their regular consumption of smokes? Is it not true that being confined to an environment crowded with people who are also mentally disordered is detrimental? How can one argue with his points? The consultant certainly couldn't.

Matthew's family agreed to his stay at the mental health ward at least until the end of the working week. It didn't seem he had blamed them, but he sure wasn't happy and I think that's appropriate. Nobody would want to be detained against their will - it is a violation of the basic principles of freedom.

It was a dilemma. Did he have good insight into his illness? He seemed to be aware of what had happened and he was able to describe his arguments meticulously. I didn't want to let this go... I promised myself I would bring it up with Dr. BB and when the time came, I did.

Me - Matthew was actually quite reasonable, wasn't he?

Dr. BB - How so?


Me - Well, I don't think this ward is very healing. He is right in being upset about not having the right to smoke, not having access to the things that usually calming him down. Do you really expect him to get better?

Dr. BB - I do think with time he will settle, particularly with medication. 


Me - What about the nature of his recovery?

Dr. BB - Yes, I see your point. What can I do about it? I don't think he is safe to be discharged. 


**Silence**

Dr. BB - I agree with you. This is not the best place for his recovery, but until he settles down, I don't have much else I can do. And I also think the family needs some time off. 

Although it's sad and unfair, Dr. BB has a responsibility to ensure the safety of his patients before they can rejoin the community, just like every other doctor. At the same time, he has to go home knowing everything he has seen everyday and be a "normal" husband, father and friend to many other people. I really wish it was as easy hanging one hat and wearing another. At the same time, I don't want to wear armour thick enough to appear dismissive the patients and not too thin to become so attached it overwhelms my family and personal life.

For all I know, Matthew was intact. His reasoning and rationale were convincing and it was hard for me to contain myself listening to him because the tragedy, for both Dr. BB and him, was that he was right.