By Dinesh Palipana
There is probably some small desire to be a hero in anyone who undertakes medicine as a profession.
Over the last three years as a doctor, I’ve seen colleagues build their careers from internship into a rich variety of clinical and non-clinical pathways. Many of my friends have remained in the hospital, a path which can sometimes even makes antiheroes of us. Others have left the hospital service.
Some have left for positive reasons. However, some have left because of difficulties with “the system”, a system which can push us beyond our limits in the worst of ways. I occasionally reflect on comments from these colleagues like, “I left because it’s such an unnatural social structure, so alien to what happens in normal life”.
Hospitals are a unique microcosm that sometimes reflect behaviours contrary to what we otherwise value as positive, or even as normal. In a 1963 article called The Social Structure of a General Hospital[1], Robert Wilson says, “Because its work goes on around the clock and its life-sustaining goals demand a maximum of self-sufficiency, the hospital constitutes an internally diverse society within a society.” I can see why this is necessary in some way. We work in a system that deals with human life. The stakes are high and errors can cause the death of someone’s child or their father. It can happen within seconds.
I can see the usefulness of a hierarchy in this business. Ultimately, the most senior person is responsible for the life of a patient. That very hierarchy though, makes the junior doctor vulnerable to the whims of their seniors. What Ryan Holiday said in his book Ego is the Enemy is true in medicine. He said, “It is a timeless fact of life that the up-and-coming must endure the abuses of the entrenched.” One’s dreams and careers are almost entirely in the hands of those who went before them, and those who now determine their future. Sadly, despite numerous programs to deter unjust treatment of junior doctors, there is still therefore little room to speak up.
We can do better. There is a difference between demonstrating good leadership and being a plain old jackass.
One night, I was working during a busy shift in the emergency department. It was just past midnight. An evening-shift intern, just several weeks into their job, wanted to hand over a patient to me. The young patient wasn’t doing well. His family was distressed. Sadly, this patient was receiving palliative care and was most likely in the terminal stage of his illness.
He was a private patient transported by ambulance into our public department for a reason I didn’t know. The family wanted him transferred back into private care: the private hospital knew him and his needs well. The intern phoned the private ward that often admitted him to ask if they’d be happy to accept him. The nurse in charge at the ward knew the patient well and agreed that they were best equipped to ensure comfort in a familiar surrounding during what might be the last hours or days of his life.
Procedure required the intern to first phone the patient’s private physician to accept their admission. This doctor unfortunately was on holidays. The next port of call was the on-call private doctor for that specialty. The diligent intern remained after their shift ended to make the phone call.
The on-call doctor verbally abused the intern: “I don’t give a **** about someone else’s patients. Don’t call me at this time of the night. Don’t do this ever again.” They continued this tirade for several minutes. I saw the distressed look on the intern’s face. They cried in the car park afterwards.
Sadly, these experiences are not unusual. In our junior years, they are frequent. Sexual harassment happens. Physical abuse happens. Discrimination happens.
Apart from the destruction caused to junior and vulnerable minds, what kind of view on leadership does this set for impressionable early-career doctors? It not only perpetuates the cycle into the next generation; the displaced negative feelings can snowball toward friends, family, peers or even patients. Sadly, it is a truth that some of our colleagues are distressed to the point of ending their lives.
Of course, in the exchange above, it was not only the intern who suffered. In what was arguably the most important juncture of his life, our patient suffered. By this point, it was ineffective to admit our patient to an inpatient ward to await acceptance of transfer to the private hospital. He would be in an unfamiliar environment with an unfamiliar care team, and so the decision was made that we would care for him in our emergency department until we could arrange transfer. In the morning, a new on-call doctor quickly accepted the patient.
Our ED provided wonderful interim care, but it was a far-from-ideal environment for this patient and his family.
In that same 1963 article, Robert Wilson said:
“Unfortunately, the patient is often the battleground of professional competition; his body, mind, and purse are scarred by the zealous attempts to do for him what each staff member specialty dictates. The hospital, too, is a battleground often ripped by a crossfire of professional purposes.”
We exist to serve the public. Our own quest for meaning and purpose – as well as our livelihood – is centred around our patients. Asking “Is this what I would want for one of my loved ones?” is a good yardstick to measure if we are delivering the best care. While doing so though, we need to look after each other. The same test of care applies in our interactions with each other: “Is this what I would want for one of my loved ones?”.
Care for our patients and care for each other are intimately entwined. One cannot exist without the other. This care includes that afforded to our colleagues who work with personal challenges, the lived experiences of which enrich the fabric of our profession.
Take depression for example. While we struggle to help a tide of patients fighting suicide, how many of our colleagues find themselves forced down this road?
The conversation extends to physical challenges too. Dr Alexandra Adams is a United Kingdom doctor with a visual and hearing challenge. In a blog piece called In the Face of Medicine: An Insight into a Medical Student’s Journey (hyperlink to https://www.dauk.org/blog/2019/7/1/guest-blog-by-dr-alexandra-adams-in-the-face-of-medicine-an-insight-into-a-medical-students-journey), Dr Adams talks about how some doctors were critical of her journey as a medical student. The patients on the other hand, were supportive.
My own experience in medicine has also been peppered with the occasional senior doctor questioning my place in the profession while I work with a spinal cord injury. One of those conversations ended with the remark, “You can’t tell anyone that I told you this myself; but you must say that it is the position of our entire department that you are not wanted here – if someone asks.” Similar to Dr Adams’ experience, the patients have been incredible.
Society is evolving. Medicine has always been a beacon of what should be right and just. As society betters in the way people treat each other – the way that we accept and enable diversity, the way that we pay attention to civility, our increased awareness of justice and equity – our profession inevitably needs to evolve as well. In fact, it behoves us to lead the evolution.
The 2010s brought us a spate of superhero movies but I ask: where are the real superheroes? Where are the people that challenge the norm? Where are the people that stand up for fairness, equity and integrity? Within our unique microcosms, there is pressure to keep the applecart safe and be politically secure. But, we can no longer shirk our moral responsibility.
For my part, I am still in clinical medicine because I have enough people in my life that are willing to stick up for what’s right. In this rich journey through medicine, I’ve learned one thing: systems don’t fix problems: people fix problems. Ordinary people can become superheroes.
Acknowledgment: “Thank you Dr. Shahina Braganza and Dr. Alex Markwell for your years of counsel and creating the opportunity to share these musings.”
WRaP EM 