On prescription drug abusers

Every now and again all doctors will come across a person who wants to access prescription medications for the wrong reasons. Some people will want them to feed their own personal addictions, and others will resell them for a profit on the streets. Personally, I am never one to judge people for their weakness or for their lifestyle choices, yet this scenario bothers most doctors for a variety of reasons. It bothers me because the false stories these people tell will make me second guess and misjudge the person who tells the same story but it is true and they have a real need for these medications. And, yes, it is also frustrating to have to deal with patients who are lying to you or who abuse your trust or become aggressive/threatening when you challenge them or deny them what they want when all you’re trying to do is get on with your daily job.

There are some government systems in place to help doctors identify people who abuse prescription drugs, but unfortunately they have big limitations. The biggest reason they probably don’t work is that a doctor has to first decide to enquire with them about a specific patient. Now, the patient who is a prescription drug abuser usually knows how not to arouse suspicion from doctors – therefore the doctor never decides to check their background! In medical school they taught us some basic things that should arouse our suspicion that a patient may be a drug abuser, but most drug abusers have figured these out and found ways to deal with us to make us believe they aren’t one of those people we learnt about all those years ago. For example, some of the things we were taught are that drug abusers tend to:

•          book the last appointment of the day (no, not anymore. If anything, they tend to be morning people)
•          ask for specific medication (they know how to calculate equivalent doses of whatever you give them if it’s from the same drug class. They also know to ask for an NSAID and paracetamol along with their opiates and benzos)
•          can’t back up their stories with clinical data (they have scars to prove the “surgery”, the medical report from the hospital, the clinical signs on examination, the old packets of the medication they have been prescribed, the imaging report, the name of the interstate specialist who looks after their condition but is unfortunately unavailable right now, etc.)
•          they become angry if you question them about drug abuse (“Oh no, doctor, not me. You can even call my specialist – oh wait, he’s not there today”…)
•          refuse referral or liason with other clinicians (you have to admire these guys’ confidence in their lies. I once was  informed by a hospital oncology department that I was the 15^th GP that week that had referred a patient for urgent review– a patient who did not actually have the metastatic cancer the CT report he provided from his interstate doctor, a doctor who knew nothing of the patient either)

Most doctors agree that a solution to the problem of prescribing to patients who abuse prescription medications is to have a real-time system of prescribing where the doctor is alerted to how many times a drug of abuse has already been prescribed to a patient. Would it work? Maybe, or maybe not. I hope it does if it's ever introduced.

To be honest, what bothers me most about the issue of prescription drug abusers is not that I was once duped by an amputee who claimed to be a war veteran but who had in fact lost a limb from intravenous drug use related disease (and not a war injury as he claimed) and I gave a script for opiates to. But that that experience made me doubt the next amputee war veteran I saw who had lost his limb through war injury and had severe phantom limb pain for which his pain specialist had prescribed a whole concoction of drugs, including opiates. Had his specialist not been available and his story backed up, I may well have let him go without receiving the proper medical care he deserved. That is my greatest fear regarding this: not that I feed a junkie’s addiction, but that I commit an injustice to a real and deserving patient.

On logical suicide

I was at an internal medicine grand rounds talk one day when a colleague started speaking about “logical suicide”; as in suicide that does not seem like the irrational choice we all have come to believe it is. Experience, philosophy, or science, have taught us that a human being’s overriding desire in life is to live. If we deviate from this, if a person wants not to live, then that human being must be ill or evil. But are there ever situations when suicide can actually be thought of as logical? It takes a little bit of tearing down of our usual norms to even contemplate this, but I was curious to explore this further.

A life worth living

In medical ethics circles you’ll often hear the terms “a life worth living” and “quality of life” banded around. What is a life worth living? Most of our lives. We have our basic physiological needs met; we have freedom to think, decide, and act accordingly; and we have (most of us, I mean) the physical capabilities to transform our desires into acts. But, then, just what is a life not worth living? You could say that it is a life that lacks those things we spoke about before, but that’s not true. You may lack any, a few, a lot, most, or all of your physical abilities and yet still consider your life worth living. The important thing is that decision on the ‘worthiness’ of your life is made by you, the owner of that life and body.

A life not worth living

The medical profession and some societal groups, though, have decided on certain broad aspects of a human being’s existence which, if lacking, deem that person’s life a “life not worth living”.  Things like if a person’s brain lacks measurable electrophysiological activity, or if the person requires constant support in their nutrition, hydration, breathing, etc. Of course, the problem with a third party deciding which life is worthy and which not worthy of living is a very fearful one. The Nazis, for example, conceived a concept of “a lifeunworthy of life”. Initially, they considered it a socially useful tact to destroy peoples who were brain dead, brain impaired, mentally retarded, or psychiatrically ill to the extent that they could not survive without the assistance of others. It was considered that these people weren’t worthy of life and in fact were unaware of what life meant, therefore, eliminating them from society (by purposely killing them) was totally acceptable. We are now all very aware that the Nazis’ category of “life unworthy of life” eventually extended to some very broad groups of people and resulted in mass killings without a logical rationale. I, am, however, now digressing…

Suicide

Why do people suicide? That is a question psychologists, scientists, doctors, religious people, and a lot of us ask every day! What do people who suicide tell us (in their last writings or after a “near miss”)? That they did it to end to the pain, that they could see no other options in their life, that they no longer wanted the mundanity of life, that they had failed beyond what they considered remediable, that they had succeeded enough that anything further would be a downhill decline which they didn’t want to face, that they had nothing left to live for, that they had more to gain in death and the afterlife, that they didn’t want to be a burden on others around them that supported them in their existence, etc., etc. People’s reasons for dying are as complex as those we live for. And yet, for most of us, living just seems like the right thing to do. Most of us don’t even question it. And when we become ill or our life is threatened in any other way, our instinct is to try to preserve it. Then what is wrong with people who want to die? People will often quote you that up to 95% of people who commit suicide have a mental illness, for example, depression. But I’ve always wondered about the other 5%. OK, OK, 4% didn’t have a diagnosed mental illness but were intoxicated with drugs or alcohol, acted impulsively after a sudden change in life circumstance, or suicided “accidentally”. But what about the remaining 1%?

Logical Suicide

I’ll start by acknowledging that I’m playing devil’s advocate here just to explore this question further. My colleague who spoke of logical suicide was in fact speaking of one of our patients. It’s not that he disliked this patient and wanted him to die, he was just saying that if this patient decided to suicide, it wouldn’t be considered a totally irrational thing to do. Of course, there were a gasps of disbelief in the room and a few chuckles thinking he was purposely trying to bring up a taboo for a few laughs. How could he speak such preposterous ideas? Because he knew the patient was very aware of his own conditions. The patient did not suffer an intellectual impairment and he knew what he had been through with his condition and that it was only going to get much worse for him. He was in constant pain and discomfort. He was still physically able to act so as to procure his own death and he was not depressed or suffering any other mental illness. Would he want to face further suffering and physical deterioration? If he didn’t, would his opinion be irrational? If he suicided, could you consider his decision illogical? What happened in that room with our colleague having raised this, is that the conversation quickly changed topic. It is still taboo to speak of these things, apparently.

Now, consider a person who, like most of us, has set an agenda for his life, something he would like to achieve and this is what motivates him day to day to keep living. For some of us this is doing a particular job, helping others, marrying the person you love, competing in a sporting race, raising your children, making music, self-expression, visiting a particular place on earth, caring for your parents, etc. These are things worth living for, for you, at least. Now, let’s consider, for example, a person whose sole motivating thing in life is to get married and have children. He wants that more than anything else in life, and that would make his life happy and complete. He is not unhappy without it, however, but he is just existing with the purpose of achieving his dream. What if he was born with a physical impairment that meant he was completely dependent on someone else to care for him and as a result wasn’t able to meet any women to have potentially fall in love with him, marry him, or have his children? He reaches 20 and hasn’t met anyone yet, online or in person. He reaches 30 and he is still in the same predicament. He reaches 40 and his parents, who are his only source of real meaningful love (but not of romantic love, which he desires), are becoming elderly and still his predicament hasn’t changed or improved. He isn’t any more likely now to a) become free of his illness, b) prevent his own physical deterioration, c) find a new overwhelming desire/purpose for his life, or d) fulfil his own self-designated mission in life. What is he living for? How does he answer that question to himself if he isn’t a religious man? Is he living to wait for his death one day?... Well, if this man suicides thinking he has nothing of value to him to live for, could you honestly say his suicide was not logical?

Living

When someone speaks of suicide, of contemplating it, we often see ourselves come up in defence of “life”. We tell the person that they should seek treatment for a mental illness, or we “remind” them how wonderful life is, or we tell them how missed they will be and how many people love and care for them, or we say that perhaps soon medical science will come up with a solution to what discourages them from life, or we tell them to think of how much they will hurt others if they go through with what they’re contemplating… We’re actually pretty good advocates for life! However, perhaps what we should be doing instead of telling others how to feel or what to think, is ask some questions of how they’ve reached their conclusions. The person most likely to convince you of something, even living, is yourself. And hearing back your own arguments for life vs. death is perhaps the only way to have a person change their minds on suicide.

Until recently we still spoke a lot on suicide prevention, but that lead to a lot of people (family, friends, religious ministers, health professionals, etc.) feeling guilty. They were feeling guilty because suicide was being discussed as purely “preventable”, which mainly implied that it could and should be prevented, and if a person succeeded in suiciding then it meant that someone (or everyone) had failed this person. The emphasis is now shifting to raising ‘suicide awareness’, to be able to recognise those at risk of suicide. Most of these people can be helped. The others we may not be able to prevent from suiciding, but we can equally help while they’re living. You don’t need to be anyone special or especially-trained to do this, all you have to do is be a human being and engage the attention of another human being. Who knows, they may just help you too.

On money and healthcare: Rights & Systems - Part 1/3

Rights

“Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services”  (Article 25, The Universal Declaration of Human Rights). The World Health Organization defines health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity”. Of course, to the majority of the world’s population, complete attainment of our human rights and of health are only ideals and not reality. Nevertheless, they are ideals worthy of our consideration.

Ideals

In an ideal world every time someone fell into an unhealthy situation (physically, mentally, or socially), he should be able to access medical health care, mental health care, or social care and have his “health” restored. He should be able to access these things regardless of the amount of money he has, his sex or age, his political or religious affiliation, his ethnicity or language, his sexual identity or practice, his birthplace or site of residence, his employment status, etc. Basically, his right to health care is universal and his human right. That’s the ideal; reality is very different for a lot of reasons.

Reality

Every country has different health care systems, which impact on the way patients access health care. Some countries will have a health care system that is exclusively government-funded and all you may need to access it is proof of citizenship to that country. Usually that means that there is no cost to the patient for an “encounter” (i.e. every time you access health care) as funds are usually derived from a portion of pooled taxes payed by that country’s citizens. Other countries may have a system where accessing health care requires payment to a private health care facility or a private company that coordinates provision of health care (e.g. supplying and paying for the medical staff’s wages, the medical equipment, the facility fees, etc.). A lot of developed countries, Australia included, operate both of these public and private health systems concurrently where the public system is the default for all citizens unable to afford private health care. The private system exists and thrives because it promises certain perks and advantages like your choice of health care provider, faster access to elective surgery, more ready access to specialist medical reviews and allied health services, and often newer premises, medical equipment, and technologies. And yet other countries have a third system, like a lot in South and Central America, a “worker’s” health care system that provides health care services exclusively to that country’s citizens whose employers pay for access to this service. The worker’s health system is closer (or equivalent) to the private health care system than to the public system. I don’t intend to argue which system is better or which worse or which country does it best, but it’s interesting to consider what’s out there.

Australia

Australia has a dual system of public and private healthcare, the public system funded from federal money and managed (for the most part) at a state level. Medicare can be considered a pool of federal monies reserved for funding certain medical services (including surgical fees and the payment for medical staff), medicines, medical aids, etc. All citizens have access to those Medicare funds provided certain criteria are met, but generally it is a default system for everyone.

An often misunderstood peculiarity of the Australian government’s Medicare system has to do with the way a doctor bills his or her patients. The Australian government decides which medical services are worthy of a Medicare rebate, the amount of money allocated to it, and the conditions under which a service qualifies for a rebate. For example, anybody may approach a general practitioner for medical care and Medicare will provide a certain benefit to the patient to pay for that consultation. The patient may also approach a specialist doctor and pay for the full cost of seeing him in his private clinic; or he may present to his GP first and obtain a written referral to the same specialist and then become eligible for a rebate from Medicare to help pay for his medical specialist appointment. (A patient not wishing to access the private medical system at all for any reason may also be referred to a specialist in one of the state’s hospitals where it is available and obtain medical specialist review free of charge.) Importantly, the Australian government decides which medical services qualify for a Medicare rebate and how much money it allocates to each service – however, how much money Medicare allocates to a service does not always reflect how much money a service actually costs to provide. Medicare in fact operates as a rebate, a subsidy to the total cost of health care, not (at least not always) as the absolute cost to cover the service. Think of it as a discount voucher, not as a voucher for a “free” service.

On "that" year

Kingaroy, QLD

2006. I was 24 still. I was a child still. But before I tell you about that year, I’ll give you a speedy run-down on my life until then. Age -9 months: my mummy meets my daddy. Age -6 months: my mummy finds out the father of her daughter is also father to 14 other children before her. Ages 0-9 years: growing up in El Salvador, a country with low literacy amongst those of my social class, and in a single-parent family where no-one has ever finished high school even. Age 6: I “decide” to become a doctor like the “cool” guy my mum works for as a cleaner/nurse. Ages 6-22: still stubborn about wanting to be like that cool guy. Age 23: finally start medical school. Ages 23-24: study, study, study. And then 2006 came along…

Things got tough for me in 2006 and my second so-called “depressive” episode happened. I lost the joy in everything, study was a hassle, I became morbidly preoccupied with my own mortality, a great solitude and loneliness came over me, and I wanted nothing because simply wanting anything required effort. The social withdrawal and pathological shyness again set inside me. Then I got into a situation where a false accusation was made against me. I was feeling pressure from my religious peers and my internalized God concept. In essence, I felt deficient. I felt lacking. And I felt dead inside – and then the feeling to externalize what I felt inside came over me. I lacked the motivation, the energy and willpower to do even that. Fearing my own internal monsters, I chose instead to go again in search of Vanessa.

Once I left everything, I felt both a great freedom and a complete hatred and fear of that freedom. There were no friends, no company on my journey, I had some advice but which felt more like orders. I had no allies – and I didn’t want anything or anyone even if there had been such people there. At first the numbness overwhelmed me and I was as a ghost walking around (which I recognized because this was not the first time in my life I have had these “episodes”). Gradually, over the next few weeks, reality and the mundane started to creep in. I needed to eat, pay bills, move, reply to the questions that were being asked of me. I started then to formulate my own questions. Who is Vanessa? And yet, not so much who is she but who does she want to be? Why does she want to be that? Does she really want to be that? What does being that entail, the practicality of it? And what of everything else? What is important? Who is important? Who, if anyone, is my friend? And what do I do with these things I love but won’t make me any income? And what should I do about these things that keep pestering me, these things others call conscience? You’ll often hear me diss and complain about the ‘white man’s stupid concept of “finding themselves”’, but you could say that that is what I set out to do.

Specifically I had some questions to answer and that was my quest in this time without commitment to study to answer. Formulating the questions was the easy part. Even finding the answers while on the quest wasn’t that hard. Finding what you’re looking for is easier when you know what it is you’re looking for. The hardest part was making the decision to take a break from my study, my big commitment at that time, to go on my quest. I risked a lot. I risked losing my friends, my family’s belief in me, jeopardising potentially years and years of prior education (and money), and losing my credibility. But I made the choice and I then had to go exploring my questions, myself, trying out different scenarios and risk finding out that my whole life had been a sham. But sometimes not knowing is as deleterious as finding out an unpleasant truth.

The second part of my task, after walking away from it all, was easy: I had the question that needed to be answered. Did I really want to do medicine as a career or was it a childhood dream of mine that I expressed and no-one ever had the courage to shut me down about it despite all the odds being stacked against me? I was a poor kid in a third world country where tertiary education costs more than entire families need to survive. It was a nice fantasy that they let me believe for a long time – until fate and relocation made my dream a possibility. But I was always a stubborn person, did I want to go into medicine purely as a whim? To prove people wrong and that I could do it? They were questions, and I answered them fairly quickly, actually. I think that giving yourself the space to not feel judged is very empowering. People may still be judging you, and I remember a lot of “friends” and even family members discounting me as a drop-out, as someone with no stamina, as a loser. But me, I gave myself the space I needed, I didn’t need anyone’s permission to explore my own life and motivations.

Like I said, the process of answering my questions took a remarkably quick time after I let go of the restraints I allowed to be placed on me by society, by other people’s expectations, by my own pride, and by my pessimism and distorted view of ‘reality’. And in the process, I learnt not only who I in fact was, but also to no longer despise myself for not being what was ‘expected’ of me. The answer to my questions were:  yes, medicine is what I, Vanessa, want to work in; and this will be a job like any other. I came to this conclusion by considering the things I enjoy (writing, visual arts, and film and theatre) and the things that I could bear to do for income. I could not bear to do anything other than medicine as income, and I’d perhaps do it even without income if something else where somehow feeding me. At the same time I was able to explore many aspects of the medical profession, and I had no grand illusions about it like a lot of people do, illusions of ‘saving’ people or of ‘making a difference’. I came to understand a lot of the industrial and organisational psychology of the business. And I became comfortable with what I learnt.

The rest came easy. The friends elected themselves by being the only ones standing when everyone else had gone. I bit the bullet and made a religious commitment. I got a “money” job because I was already planning for my future and my dream to see the wild condors in the Andes in South America. I in fact spent the remaining months of that year killing time by working and entertaining myself until my return to uni and getting on with my task of achieving the next task on the journey. So guess what I do now for work? Medicine. And guess what I do for passion? Write. And I can now unashamedly say that my name is Vanessa and I know exactly who Vanessa is.

Condor! Colca Canyon - Arequipa, Peru

On doctors... Part 2

Just as I thought I’d finished this post, I remembered what exactly I set out to do: provide a dual view of people’s experience of health care. Now, it may seem that above I was just taking a defensive stance to explain what is experienced by the doctor himself compared to what the non-medical population, our patients, expect. But it must be acknowledged that a lot of patients do have these, perhaps out of date, perception of doctors – and doctors would be callous for overlooking this!

It’s already established that a doctor has a very specialized knowledge, access to which you can ‘buy’ for the cost of a consultation fee. However, this knowledge is of value to every human being because it deals with something that affects you directly and in the flesh. Access to this knowledge, the service the doctor provides, could potentially save your very life – there are very few services this could be said of! Patients know this and that is why they seek them. Doctors have to equally acknowledge this, so as to fulfil our duties (for which we are being paid for). Generally, people do not present to a doctor just to hand over some money for the consult fee and waste some time. Generally, they pay their fees in order that the doctor provides advice and or treatment for a sub-optimal machine fragment. That is an important thing for an ethical doctor to realise. Now, I say ethical speaking of work ethic more so than moral or philosophical ethic. If you paid a mechanic to fix the gearbox in your car and he dismissed your concern about it because he doesn’t feel motivated to work currently, and he did nothing to repair or investigate the problem in your gearbox, then charged you his mechanic’s fee, what would you think? You would think he has a poor work ethic, not necessarily that he’s an immoral person or that he’s not a good mechanic; quite simply he has not done what he was paid to do.

Patients don’t go to see their doctors when they are happy and healthy and life is grand. They seek the doctors when they are in need. And that to me is one of the biggest realisations a lot of doctors fail to make. Even the patients that abuse us, that blame us, that threaten and disrespect us, did not come to us without a need. Perhaps it may even be that they need treatment for their abusive behaviours and just haven’t realised it. But patients don’t present to us to waste our time. They perhaps have expectations of us that are above reality, but they do have basic needs that are not being met – and sometimes the cheapest treatment we can offer them is to acknowledge and validate their concerns.

Having said that, I can only emphasize that medicine as an industry does not always obey your standard commercial industry rule to give the client exactly what he asks for. You may ask someone to sell you a plank of wood of a particular length and he will gladly comply and bill you accordingly, but from a doctor you buy a service, not a product on its own. For example, if a patient attends a new doctor demanding a script for a drug of dependence, that doctor is not obliged to hand over a script at the end of the consultation. He is required to perform a consultation and apply his special skills to determine what the treatment indicated is, which may or may not be to provide a script for a drug. And in that, the medical profession differs because we do have a duty to both aim to improve the patient’s health and also to prevent negative health effects. A doctor does not sell prescriptions, investigation requests, or referrals to other health professionals in exchange for your consult fee. No, he sells his time and specialized knowledge, which may require referral, investigation, or medicinal or surgical treatment.

I suppose if I have to summarize this whole two-part rant I’d say I was trying to make two points: 1) Doctors are normal people doing special jobs, and 2) Doctors would be silly not to acknowledge that the non-medical public does attribute some beyond-human qualities to them. People do the jobs they do for different reasons. Medicine is also a job, but a special one in the personal and direct nature of it. As human beings engaging in human-human relations, both doctor and patient in the relationship need to acknowledge the fact that we are all deserving of the same respect and care owed to each human being aside from our duty in the transaction.

On doctors... Part 1

I particularly hate labels because of the stereotypes, often negative, associated with them. But today I will discuss doctors, as a label, just like the non-medical world sees/believes it. Now, I am during the hours of 8am-6pm, Monday to Friday, also one of these doctors so I will aim to give you some insight into what this is actually about.

Traditionally medicine as a field of study (science or art, as you choose to see it) was something that was practiced by a select, if not elite group of people. Guys from the times of Hippocrates were taught by apprenticeship. They had a code of practice, and they were taught by and from the knowledge others before them had acquired. Those chosen to partake in the training to practice medicine were children of the wealthy, of other doctors, and other persons who excelled academically or otherwise, etc. It was an elite group acquiring a very specialized knowledge. Their superior knowledge and skills on which others from the village depended on placed them in greater standing in their communities. They were people to be respected, protected, renumerated, and admired for their service to the community. Such behaviour was totally understandable when it’s considered how many people in a village one physician was entrusted with caring for (often for a fee because these were rarely men of religion or charity).

Fast track to modern times and a lot of people still have the belief that doctors are special people. They believe they are smart, inherently “good”, of high moral standing, wealthy, caring, and just somehow different to other human beings. Now let me consider a few of these points. Actually, first let me consider what it means in modern times to be a functional human being. A man or woman living in modern times needs nutrition, shelter, psychosocial support (usually family and friends), industry, recreation, self-efficacy and satisfaction, and the money to be able to afford a lot of these things. Doctors are human beings too. Doctors also need these things. Doctors are human beings who are practitioners of a particular profession – but they are first and foremost human beings born of other human beings and of the same substance of every other human being on this planet.

I will start by discussing first the most banal of subjects, because it is a subject neither doctors or non-doctors like to associate to the profession: money. A doctor is a person whose job it is to deal with other human beings in order to improve their health or wellbeing. Note first that he is a human being doing a job. Jobs are done for money. A doctor needs money the same way everyone else needs money. You can’t walk into a supermarket and grab your groceries and tell the checkout personnel that you won’t be handing over money for your items because you are a doctor. No! It’s absurd. Money is demanded of doctors the same way and for the same things it is demanded of any other human being. What makes people uneasy about this discussion is no-one likes to think that a monetary value can be placed on preserving or improving the wellbeing of another person – but try doing it without it! How without money can you buy the equipment you need to exercise your profession, to feed and clothe yourself, and to enjoy the recreation all human beings are entitled to? A doctor provides a service, a product if you will, a specialized service; in return a fee is charged for this service. There is nothing abnormal about this. Teachers, engineers, shop assistants (not shop owners), prostitutes, psychologists, and even a lot of clerics, do it. Are they bad people for practising a human profession? No. They are workers employed to render a service for compensation. To deny that doctors don’t think about money and how to make it is like to deny that they eat and breathe and defecate just like any other person on this planet. Interestingly enough, unlike the nursing profession, medicine was never so inherently related to charity and religious servitude. A medical man was always separate to the concept of providing charity; he always provided a service for which material reward was often gifted/charged/expected.

The other common misconception is that doctors are somehow different, or better people, than others. Well, what kind of people go into the medical field these days? All kinds of persons. People of wealthy families, people of poorer families, people who are religious, people who are atheist, people who are accepting and welcoming, people who have prejudices, people with high academic scores, and people of not so high academic scores. At the end of your medical school training all these people are awarded (or earn) medical degrees. The prejudiced guy’s degree and that of the religious girl are both equal – and they both are now doctors. The medical schools teach you medicine, not how to be a “good” human being. Therefore, post-graduation the only thing in common of the graduands is their medical degree not their moral standing or wealth or religious views or any other societal variable. A person with a medical degree is still just that, a person. To say “doctors are special” is like saying “children like birds”. Some children like them, others hate them, some of them don’t even notice them, some wouldn’t even know a bird if one stood on its head. What am I trying to say? There are as many “good” doctors proportionately as there are “good” people in this Earth.

Lastly, I want to consider the concept of the ‘caring’ professions. One complaint patients sometimes make of doctors is that they don’t care. Now, remembering what I just discussed about how different sorts of people enter the medical profession, we have to consider that the reasons that people do go into medicine are also varied. For example, a person may go into medicine for some perceived social higher standing, because it is a profession in which continual education is inescapable, because they find biology and science fascinating, because they want to be of assistance to other human beings, because they enjoy certain technical aspects of surgery or procedural medicine, because they enjoy interacting with other human beings, because science and biology was something they were good at academically at school so they may as well use it in their work… the list is endless. Of course, most members of the non-medical community assume all doctors have gone into work in the medical field because they ‘want to help others’ or because they care about human beings to the devout (and also sacrificial) extent a religious minister might. These patients are often disappointed by the doctor who treats them as a client receiving a service (which they are) and not as a saint tending to his disciples’ every need. Medicine is a health care profession, not a ‘caring’ one that implies caring for things other than the person’s health. Your fees pay for a doctor to render a health care service, his specialized knowledge.

Of course, I am not saying all doctors are uncaring, money-hungry, immoral people who care only about themselves. No. Neither am I encouraging the general belief that doctors are superior, all-knowing, all-caring angels of God sent here to heal people of all their woes, health-related or otherwise. What I am saying is doctors are human beings. Human beings doing special jobs, but they are just human beings no more special than any of their patients.

On the human factor... and the risks of work

As anyone who has ever done a job that involves interacting with another human being will tell you, it's often the human factor that ruins most things. In fact it can ruin it so much you can start to lose your will to live. Let me describe one scenario that is all too familiar for anyone who’s ever worked a junior doctor job in a hospital:

Say the procedure is: patient is 1 year old and has a tumour, patient needs pre-op MRI, patient needs surgery, patient then needs post-op MRI. The actual procedure becomes: need to talk to the patient’s parents about the surgery, risks, etc. You then have to organise the pre-op MRI, which is absolutely necessary for surgical planning – and everyone knows this – but either way someone will have a go at you about because you’re requesting it be done today or tomorrow because the surgery is to be done tomorrow and the boss only told you about it today and the patient did not ask for their tumour to be diagnosed only yesterday. Then you have to discuss the case with the anaesthetist who tells you that you need to put an IV cannula in this child before he gets to theatre, although you tell him that the only accessible vein in this child is in his neck and it took another consultant anaesthetist 2 hours to get a cannula in him last time. Somehow, he tells you, the patient’s poor venous access is your fault and you’re incompetent for not being able to cannulate the child. Eventually the kid gets the surgery (after the 2 hours it took the anaesthetist to find a vein in the child) and you have to talk to the parents again because they're worried something went wrong, they think someone somewhere stuffed up and it's someone's fault, and they get all unpleasant towards you even though you're trying to explain to them that their child is just post-op and they'll improve or that it was a risk you had discussed with them previously, etc. Then you try to organise a post-op MRI and the radiologist decides to pick this occasion to tell you how surgical teams do too many scans, that they don't plan them right, that they order unnecessary investigations, that you personally are a crap clinician, that you don't understand how the MRI machine works, that you are wrong and your patient doesn't need the scan... but they'll do it anyway. So by this stage everything that needs getting done IS getting done BUT all these people have in the meantime made you feel so negative about yourself that you start to wonder if it was all worth it. Like, really, why must it be you that cops the abuse? Your role could easily be filled by someone else who knows how to fill in the forms and talk to people (aka the majority of the tasks the junior doctor job actually involves). So why must it be you? Why? Seriously. Hopefully the kid gets better, and maybe you had something to do with it, but you'll never think of it that way, and the family or the patient will never thank you, so all you remember from the interaction is the abuse everyone laid on you and how small you felt afterwards. Was it worth it? Was removing that child's tumour worth you self-esteem? Was it worth losing your self-worth? Was it worth losing your passion for your job, the big picture? And maybe, just in some, the question becomes ‘was it worth losing your will to live’?

Okay, so maybe the final statement was a bit of an exaggeration but it is not describing a new phenomenon. I always remember that story from ‘House of God’ about the medical intern that suicides and how every year a certain percentage of doctors do. But the phenomenon, of course, isn’t limited to health professionals. Cliff Baxter, one of the executives of Enron Corporation (the U.S. energy company that went bust in 2001), suicided after he was indicted to court for his role in the Enron bankruptcy case. In his suicide letter he wrote, “where there was once great pride, now it’s gone”. As an executive of a corporation like Enron was, Cliff Baxter wasn’t a weak or stupid man, but to me at least, his story warns about the risk of defining yourself by your job. I find it sad to think that having a wife and children, he saw his life as not worth living because he could no longer live with pride for his work. What about living for his wife or his child? What about living because there are other things in life besides work? I can’t help but feel that if you have to rely on your job to make you feel satisfied, to make your life feel like it is worth living, to make you happy, then you’re probably lacking something very important and beautiful in your life.

They say that doctors are especially prone to what is commonly called “burnout”, in general, for the same reasons that they have chosen to become doctors: they are often perfectionists and have a high sense of responsibility. In the workplace these are exactly the things patients and their relatives appreciate and expect. Other co-workers also expect the same thing from them. And what’s more, eventually the doctor comes to expect this of himself. So then he starts going home late to make sure everything is OK (a.k.a. “stable”) before he leaves. He’ll work all the ridiculous shifts and hours he is told to because he’s expected to and no-one before him has been able to change the system so he just has to submit. Of course, with all the time (and let’s not forget effort) dedicated to work and career progression, he spends less and less time with family, socializing, relaxing, and essentially doing all those things that truly enrich human life. It’s then easy to imagine how with work consuming so much of your life, a person could come to define themselves solely by their work. You start to associate success exclusively with occupational achievements and less with the attainment of personal, family, or social goals. Proverbially, you come to ‘live to work’ not ‘work to live’. And once you come to do that, it is not so far-fetched to imagine guys like Cliff Baxter who, having lost his ability to work, come to believe that he has also lost the ability to live.

On work

When I was a little kid I said “I want to be a doctor” the same way a lot of children say it. Now, I was at the time living in a third world country in the middle of a civil war and I came from a very large and poor family, so saying that was the equivalent to saying I wanted to be an oil magnate or something highly improbable like that. A few things happened to me, though, that don’t usually happen to most other people in my situation. Firstly, I was always incredibly stubborn so even a decision I made when I was six years old, was to me a life decision, a plan. Secondly, I had a family that didn’t shut my dreams down with the reality that kids from poor families in El Salvador don’t make it to university to study. The one thing that really drastically improved the chances of my childhood wish becoming a reality, though, was moving to Australia when I was nine.

Now, I went through my schooling in Australia fairly seamlessly. There was a period in year 11 when I lost interest in school because I found out that not a lot of other people thought like me, and I found it hard to understand how people can just claim authority over someone else and expect obedience from them. At the end of that year, though, I realised that I should obey silly things like going to my allocated class and not just doing the assessment if I was to make it into university. From the end of high school the plan was pretty straight forward: get an undergraduate degree in something I was good at (science) and then medical school, etc.

Everything went as planned until I finished my science degree because I didn’t make it into medical school straight away. I went for an interview at an interstate university and was so incredibly sick the day before I thought I was going to die. I even called my brother to tell him that if I died he could have my things, but in the end I didn’t have the courage to tell him that. The interview went horribly and I was left with a science degree I could do little with except post-graduate study in something boring and uninspiring.
I enrolled for post-graduate study in science and even managed to score myself a scholarship for that year.

My research project used a mice model so it involved a lot of time in a lab doing very fine and repetitive tasks. The lab I was working in was on top of this hill, on the top floor of the research building, and had a large clear window at the back from which I could see the world passing me by. I used to look out of the window all the time, feeling ashamed that I was there locked up in such a sterile environment wishing I was dead while the sun shone so brightly outside and everything outside of that place seemed to actually be alive. I grew increasingly more dark working in that place, dreading every day and its boredom, it’s repetitiveness, it’s staleness. I became quite sick and one day I decided, against everyone’s advice, that I wanted to re-learn what it was to be alive. Everyone told me that I may as well finish the year off, to not waste the last six or so months of my life. I told them that I had just wasted those months of my life and didn’t wasn’t to waste another three months feeling like I was dead inside. I had wanted to convince myself that perhaps medical research could work for me as a profession, but I found out the hard way that I couldn’t stand it.

That year again I tried and failed to gain entry to medical school, so after I quit my post-grad course, I decided to dedicate my time to learn to live again, to learn how to be Vanessa. That’s when I started writing again. It helped me sort out a lot of things inside me, to learn more from nature and about myself. The following year, I decided to go back to uni to do something fun and that met my interests, so I did a one-year course in my one true passion: creative writing. It was so much fun and really suited my needs. That year I applied and got an interview for medical school and was finally accepted into the course.

Medical school I soon learnt was a lot like high-school except for the teaching methods. It was largely uneventful until my third year when I had to do a rural placement outside of Brisbane. It was the first time I had been away from home and I’d just done a rotation I didn’t enjoy and was very badly treated by a member of the hospital and teaching staff. I was already struggling with feelings of low mood and motivation by the time my placement started, which were only exacerbated by the isolation. I tried my best to stay focused on just doing the work, being a machine that just does its work and then switches off until the next day. The only problem was that I can’t do that, I’m too sentient, and at that time I had very few mature coping strategies. Again I started to feel as I had when I was doing the post-grad science studies: dead and waiting only to die physically. I persisted for a few weeks by numbing myself out, but one day I remembered what it was like to enjoy living ,so I then realized I needed to regain that before I could go on with my studies. I withdrew from my course, returning home midway through my placement. What was strange to see then was the number of people (family, friends, and colleagues) who so quickly dismissed me as a dropout, lacking ambition, lacking passion for medicine, just severely lacking. I never once floundered in my desire, though, I wanted to work in medicine but I knew that was not the right time for me.

During my time away, I just continued writing, going for long walks, meeting a lot of new interesting people, and working to save up for a holiday I had planned for the following year. One of the key questions I wanted to answer for myself during my break was ‘why am I doing med?’ My fear had always been that it was just something I had said as a kid and was encouraged too forcefully by my family. If I had said I wanted to be a drug dealer, for example, I may have wanted it as stubbornly but my family would never had encouraged it. I started working a job in retail for some money, and looked at what other professions were around. Eventually I realised that med was the only job I could imagine doing, the only work I wanted to do if we as humans must work for survival, the only job in which I could see myself not hating my own existence every day. But I was never naive as to what a medical job actually was and so I knew that if I was going to continue with it, I had to acknowledge that it is just that: a job. A very privileged job, at that, in that it gives you the opportunity to help unrelated others to continue on with their lives with the burden of their physical troubles eased, but still just a job. And a job is just that; it’s not your reason for living, it’s not what keeps you warm at night, not what embraces you when you’re exhausted. I want my work not to be my place of solace; that’s what I want my home to be. I want to go home at the end of my work day and feel at peace. I want to look forward to going home at the end of the day, to have something truly special there to go home to, to someone that will hold me.

When I was much much younger I considered doing foreign aid work in medicine to help those in need. I considered it for the same altruistic reasons most people do (whatever that means). As I got older, though, I started reflecting on my own life and decided that it wasn’t for me. I have seen enough poverty, conflict, and war in my life. And maybe I should be returning a favour, but quite frankly I am satisfied with my life as it now and I don’t owe anyone but God anything. I commend those who do aid work, it is truly a great act, but I know it’s not for me.

In 2007 I returned to medical school to finish off both my rural placement and also the rest of med school. The rest of it was uneventful, except for meeting some very rare people who I found to be very decent human beings. I also took the time to learn a lot more, not so much about the medicine as I should have been doing, but rather about the organisational psychology of the industry. I learnt a lot. I got to know a lot of people, to observe countless interactions between what in any other place are just human beings but in that sphere are doctors, nurses, pharmacists, physiotherapists, wardsmen, administration officers, etc. and are governed by this artificial and impalpable law of hierarchy. I learnt the rules of the game. I learnt a lot about governance and of how humanity is so often absent from the human professions. Oh well, I learnt a lot and I never entered the workforce naive to these things.

And so here I am, doing the only job I have ever wanted to do. And here I am, loving not my job but the place I return to after work is finished. And life is exactly how I wanted it to be.