What Kills You... And What Makes You Stronger.

It is my first fortnight on General Medicine and it has been brutal.

Not only has there been the compulsory Week 1 breakdown, there has been around 6 breakdowns in the past 12 days.

While covering the wards last weekend, I felt completely burnt out. But of course, Monday came along so I kept on going.

That's just what you do.

I started out the year on my 20-week GP rotation, and I loved every minute of it. Moving on to Orthopaedics was tough, but as the trend seems to go, you find that you start to get the hang of things by Week 9, only to switch rotations after Week 10 and end up back where you started - lost in unfamiliar surroundings.

All throughout my internship year thus far, there have been ups and downs, but ultimately I have found that I've been enjoying my training tremendously and even at the worse of times, I love what I do.

General Medicine, however, has been hard. It's a hard unlike anything else I have ever known.

It's the kind of hard that makes you run like your life depended on it, then knocks the wind out of you and then as you crash to the ground, delivers a fatal blow to the back of your skull.

You don't want to get back up, but you do anyway.

What makes you do this?

The fact that you don't have a choice.

It's do or die.

I started my rotation thinking of what a great opportunity this would be to learn and grow in my clinical skills and experience. But now I just feel bruised and battered. I'm just tired.

The real danger is that exhaustion has a tendency of beating the enthusiasm out of you. In the past fortnight I've tried so hard to struggle through the exhaustion and to fight off the apathy. It has not been easy, and it required me to call upon an internal strength that I did not know I had.

Now that I'm finally facing my first day off since starting on Gen Med, I still find my thoughts stuck on the wards. It's a form of psychological trauma.

Have I done all the blood slips for the weekend? Are there investigations that I haven't followed up? Have I missed something important?

That's the problem with hospital medicine. The work never ends and as everyone else has their own work to do, there's no one to cover you if for whatever reason you don't do yours.

And at the end of the day, after being so invested in the treatment and progress of so many patients, it's hard to just shut off when you finally get to leave the wards.

Another problem with hospital medicine is the high turnover rates and the high patient load. As an intern, your days are busy and there are always investigation results to chase up, referrals to be made, tests to order, notes and drug charts to write up, admissions to be done.

The work is constant, and a reliable pen is your best friend. With my 30 - 40 patients a day load in the past fortnight, I have very easily run dry a total of 4 pens.

With the nature of the job being so task-oriented, it's very easy to lose sight of why you're there. It's also easy to lose the empathy - there are just too many pressures on you at any one time, and when you're struggling to catch your own breath, it's very easy to inadvertently look over someone else who is also struggling to breathe.

Rather unfortunately, their lives depend on you. So sink or swim, your patients are your priority.

Rightly or wrongly, medicine involves a lot of self-sacrifice. It involves sacrificing your time, your life, yourself, for someone else, simply by virtue of the role that you choose to take on by being a doctor.

We are told on airplanes that when cabin pressures are low, you first need to put the oxygen mask on yourself before attending to those under your care.

It's an important principle, but unfortunately the medical world has not yet adopted this principle. It is expected that doctors take care of themselves, but the nature of the work and the hours that we work do not logistically allow us to do this.

It is undeniable though that when exposed to a consistent state of low oxygen, the body learns to adapt. We learn to function at a much higher level than most under much less desirable circumstances. We become stronger.

Still, there is a fine line between learning to thrive under extreme circumstances and failing to thrive. Everybody has a limit and often the factors that test those limits are not within our control.

Sometimes it feels like a game of chance. Like Russian-Roulette.

If you're pushed hard enough... Who is going to be the next to have a breakdown?... Who is going to be the next to make a mistake?...

Who is going to be the next one to stop caring?...

Because when the work ceases to be fun... When it starts feeling like a chore and all you do is rush about doing your daily jobs to get them all done before midnight, which is 2 hours past the time you were meant to leave, knowing full well that you have to be back at work at 6am...

When you're pushed so hard that your own reserve tanks of hope, love and joy run empty and you couldn't care less about anyone else's wellbeing...

That's when it ceases to be good medicine.

Work

I've often marvelled at how amazing it is to be granted the privilege to do the work that I do.

It truly is a privilege to be able to wake up every morning, go to work and care for the sick.

To be able to gain insight into their lives, to help make them better, to be trusted with their stories and their secrets, to have their families trust you to care for the ones they hold most dear; it is an extraordinarily humbling profession.

Today came with a lot of 'firsts' for me:

1. I managed my first acutely unwell patient from start to finish
2. I took my first set of ABGs
3. I experienced my first "breaking of bad news"
4. I certified my first death

It's been a long 16-hour day, and I start up again in 6 hours, so I should probably get some sleep.

The thing is... Given the day I've had, it's not exactly easy to come home at the end of the day and wind down. The adrenaline, which is so crucial to keeping you going while you're at work, doesn't just switch off when you leave the hospital. It takes time to wear off.

But now that the silence has overcome me, I'm ready to call it a night.

And at the end of the day, this is what I think about being a doctor:

The job is hard, but the work is good.

When you put everything you have into it, you start to get into the flow of things and it just feels right. And when everyone works together and does their part well, it feels like a symphony.

You cannot do medicine by halves, and I cannot think of anything else I'd rather be doing.

I love my job.

Hotel California

Medical Internship is a little like going to war.

A lot happens, some of it traumatising, and at the end of the day, you don't really want to talk about it.

Since I've decided to chronicle my internship year however, it would be remiss of me to back out of it now.

So let's get ourselves up to speed.

At present:

- I have just completed my second week of Orthopaedic Surgery, in which I have worked between 11 and 16 hours without breaks

- I have been working for 12 days straight, 3 of which have been a long weekend cover shift, in which I covered the Orthopaedic ward, along with General Surgery, ENT, Urology and Rehab

The work is good and I really enjoy it. However, my work is all I have been doing for the past 12 days.

In the past fortnight, I have felt unrested, uncleansed, and unfed. If you walked into my apartment you'll find a pile of dirty dishes in the sink, a pile of dirty laundry on the floor, a rubbish bin full to the brim, and piles and piles of things around the place which have yet to be unpacked from when I "moved in" two Sundays ago.

I leave for work before the sun rises and I return from work after the sun has long set. This is not an unusual pattern of schedule for a medical professional, but it does not mean that it is right.

All it means is that all I want to do when I get home from work is sleep. All other aspects of my life outside of work - family, friends, recreational activities... All things that make me sane - are all placed on the back burner; as if you're familiar with Maslow's hierarchy of needs, you'll know that physiological needs tend to raise above those of safety, love, esteem and belonging.

Regardless, I've had a good first fortnight. I love my patients, my colleagues are a pleasure to work with, and the administration provide me with a lot of support and encouragement. All these factors make me feel like I'm working for a purpose - a worthwhile cause - and that I'm a part of something much bigger that I, and that is good quality healthcare.

The only problem with me working 12 days in a row, other than exhaustion, life neglect and sleep deprivation, is the fact that it is so hard to leave when you eventually do get some time off.

I am in Melbourne this weekend to attend my interview and entrance exam to get into the General Practice Training Programme and while I'm aware that my thoughts and attention should be here with me, I can't help but wonder about my patients in hospital and how they are doing.

I wonder if the interventions I performed yesterday helped at all. I wonder if any of my patients are getting discharged over the weekend. I wonder if anything eventful occurred overnight (and I hope the answer to this is, No).

It makes me feel like the hospital is a little bit like Hotel California.

You can check out any time you'd like (assuming it's rostered), but you can never leave.

The Sick Doctor

One of the hardest things for a doctor to do is to be a patient.

There are many factors that contribute to doctors not being able to take on the sick role, and it's often not as straight forward as simply not wanting to.

For starters, all doctors know that there is a gradient to being sick, and theoretically, there is a point in that gradient line in which you are deemed "too sick to go to work".

However, in practice, it's actually very, very difficult to properly ascertain where you are on that list. It is hard to be objective when it concerns your own health, which is why it is always valuable for a doctor to have their own personal doctor; an independent assessor capable of making the call that you should be off-duty.

Why is it important to have someone to take that decision away from you?

It can be very easy for a doctor to say "It's just a cold, I'll soldier on" because a lot of the time, it takes a lot more effort to take a sick day than it is to just go to work even though you shouldn't. For a specialist, it means rescheduling appointments that have been booked months in advance; for interns, residents, and registrars, it means finding someone else to do the work you were assigned to do.

Whether in hospital or in clinic, when you're a doctor, there's always more work to be done than there are hours in a day. And more often than not, you're the only one who can do your job because other doctors have way too much on their plate already. Quite simply, there is no one to pick up your slack.

It is undeniable, however, that a sick doctor is no good to anyone. Not only do you risk spreading illness to your patients and colleagues (further contributing to countless hours of loss productivity), your physical, mental and emotional states are compromised and you're more likely to make mistakes.

And in medicine, mistakes are costly and not tolerated very well.

All the same, there seems to exist an expectation within the medical profession, conscious or subconscious, for doctors to push through adversities. Whether it's related to physical, mental, or emotional drain; whether it's due to excessive working hours, unpaid overtime, lack of personal or professional support, work or life stressors or illness of any sort, we all seem to be expected to suck it up and be okay anyway.

Despite being constantly reminded throughout medical school about the importance of taking care of ones health, the comment one of my supervisors made regarding my need to get some time off to visit the doctor was, "Do that while you can, because when you get to my level, there's no such thing as taking time off. When I get sick, I still have to go to work."

And therein lies the hypocrisy of medicine. What they tell you to do and what they really expect you to do are often two completely different things.

One of my colleagues recently confessed to me that she has been struggling with the hours and jobs required of her in her medical rotation. In fact, she was having such a hard time at work that she felt she needed to bring the matter up with the Director of Medical Services so they could together find a solution that could improve her situation.

The response she was met with was appalling. The DCT essentially said, "Suck it up, this is medicine, when I was at your level I had it 100 times worse. I'd be lucky to have a rotation like yours."

My thoughts? Tyrant.

And this is not an uncommon scenario.

My personal thoughts are, it doesn't matter that back in "the good old days" doctors were expected to slave over inhumane hours which were both hazardous to their health and their patients' health. There's a reason why we have put a stop to the Dark Ages. It wasn't working for us. Just because you had it hard, doesn't mean that it's okay; and it definitely doesn't mean that you need to condemn others to the same fate. 

In that regard, I have a lot of respect for the nursing profession. Nurses adhere religiously to their stop and start times, they take multiple schedules breaks a day, and are extremely ferocious about guarding these sacred rights. And, more importantly, they look out for each other. They ensure that their fellow nurses take breaks and leave when they're supposed to.

The habit is so inspiring that I can't help but wish that they were just as watchful over their doctor colleagues!

Unlike a lot of my colleagues, I've been very lucky in my rotation so far and I've had wonderful, amazing nurses working with me who care about my health and wellbeing. In fact, it was under the advice of a senior nurse that I took my sick leave and I'm very grateful to her for pushing for it. I had really needed it, but the weight of my supervisor's expectations (and my own) was urging me to push on.

At the end of the day, we are a team. And like any team, we are only as weak as our weakest link. I think it's important for us to look out for one another and stand up for one another when the occasion calls for it.

We all acknowledge that no one is superhuman. We are not immune to disease and when we come across someone who needs a hand with taking on the sick role when they rightfully deserve it, I'd like to think that we could defend that persons right, just like we would want someone to defend our own rights to it when the time comes.

It is incredibly sad to note that, from my observations thus far, compassion is a virtue that is incredibly scarce in the medical profession, despite the fact that it requires it most.

It is both frustrating and disappointing, and I can only hope that this improves in my future observations but until then, I suppose the most I can do is to follow Ghandi's advice and be the change I wish to see in the world.

GP-Land

This week has been particularly stressful.

But I'm sure I say that every week.

Amidst having plenty of complicated cases present at the clinic, I also had to suture a laceration yesterday that was approximately 10cm in length, and fairly gaping.

It was good practice, I was thankful for the opportunity to further my experience, and I feel I did a good job. Still, my neck and back ached by the end of it, and as soon I was done, I had to rush to the hospital to give a presentation about Wide Complex Tachycardia to an audience of consultants, registrars, interns, medical students, and nurses. Oh, and also the President of the Royal Australasian College of Physicians.

No pressure.

Thankfully, with a lot of preparation and a touch of good luck, the presentation went well and I felt really positive about it. I was a massive wreck in the couple of months preparing for it though! It's nice to be able to look at it retrospectively and say that it was a success.

I'm currently on my 11th week of General Practice and around week 9, I finally felt like I was getting the hang of things. Given that all the rotations in our internship year (other than GP, if you're in my internship programme) is 10 weeks in duration, it's a little unfortunate that you only feel like you've finally got the job down just before they ship you off to another one.

But that's the nature of internship training, I guess. They like to keep us on our toes.

I like General Practice. That was one of the main reasons I selected my internship programme. I figured that after 20 weeks of GP, surely I'd have a better idea about whether or not I'd pursue it as a career.

What I've found, however, is that although I still find GP-Land a nice place to be I'm, I've developed a thirst for other specialties, particularly Emergency and Paediatrics.

I have an ED rotation at the end of the year, and I'm very much looking forward to that. I'd like to look into getting some experience in Paediatrics next year as well. And, of course, I still could be a General Practitioner and sub-specialise in Emergency and Paediatrics.

Decisions, decisions...

The good news is, I'm in no rush to decide.

Sleep

I have just come home from the hospital after attending to patients who were affected by a tornado that's hit not too far from here, and all I want to do... Is read.

I know I should be sleeping.

I still need to go to work tomorrow morning, as I have patients booked in to see me. I still might get called back in tonight if we received any more admissions. And I've been in theatre all day after having very little sleep the night before due to a case of food poisoning.

So, yes... I'm well aware that I should be sleeping. But I'm wide awake.

I'm finding myself flipping through my medical textbooks, looking for more information. My mind feels thirsty for knowledge... I feel like I need to fill it, refresh it, with questions to ask, symptoms and signs to look out for, medications and dosages... All for the next patient that comes through those hospital doors.

I want to be good at this. I don't want to miss anything.

Which is why... Despite not wanting to... I'm going to power off my brain and get some sleep.

It's counter-intuitive to me at the moment, but I know it's the right things to do.

I need it.

Heal Thyself

It is a fact universally acknowledged that in comparison to a large proportion of the general population, doctors are paid relatively well.

If the perspective of someone working in this field is anything to go by, there are some days when you realise that you are not paid nearly enough for the work that you are expected to do.

Being a doctor is hard.

And being a good doctor? That's even harder.

The job is time intensive, labour intensive, stress filled, all consuming, unhealthy and often thankless.

People have asked me, what's it like being a new doctor?

I smile and say, it's fantastic, and on most days, this is true.

But then there are days when what I really want to say is this:

It's like going to work in the morning, finding out that one of your patients has unexpectedly died overnight and wondering... What exactly happened? How could this have happened? Was it something I've done? Was it something I didn't do? How do I fix this?

But you can't.

It's like finishing a 36-hour shift (or an 8-hour shift or a 14-hour shift), making your way back home and not being able to shake the feeling that you've forgotten something... And you hope and you pray that whatever you've missed wasn't something big. And you lay at bed at night thinking... Have I done something today that might have adverse effects on someone's quality of life? Have I done something wrong that can't be fixed?

But your head is cloudy from fatigue and the day is all a blur and you remember next to nothing, as hard as you might try.

And after a while, you are overwhelmed by the futility in wondering and you pass out from exhaustion.

Or... You stay awake in bed. Which is worse.

You stay awake in bed, fully aware that in a short couple of hours, you will be expected to be on the wards once again. And the longer it takes to get to sleep, the less sleep you will get, the more of a zombie you will be in the morning and the more mistakes you will make.

If you're lucky, the anxiety and adrenaline eventually wears off and you find yourself asleep. Until, that is... You find yourself waking up in the middle of the night, every hour, wondering... Is it time for work yet? Should I be getting up now? Am I late for work? Where's that ward list that I needed to update?

What is it like being a new doctor?

It's like feeling exhausted after a long shift and wanting nothing more than to drive home and get into bed but knowing that driving after being awake for as long as you have is extremely unsafe. In fact, it's like you've got a blood alcohol that's above the legal limit.

So here's the question... If you're not allowed to drive in that state, how on Earth would it ever make sense that you'd be allowed to prescribe lethal drugs or make life and death decisions? How could you ever be expected to be sharp enough not to miss anything?

But you are.

As a doctor, you're expected to function at 100%, 100% of the time.

Your days consist of answering questions. Questions from patients, families, senior staff, junior staff, students, other members of the healthcare team... All of which you will be expected to know how to answer. You are expected to know everything about everything at all times.

As a doctor, your job is to care for other people, regardless of how you're feeling. If you show up to work and you're sick/tired/depressed/run down, well, suck it up, princess. There's only room for one sick person in a consulting room, and you're not it.

There are days when you think, I would give an arm and a leg for just one more hour of sleep, and those are the days when the money isn't worth it.

You lay in bed, unable to move, and you think, can't I just pay them to let me stay in bed? If I have a mental break down, will they finally leave me alone?

At that stage, the prospects of becoming criminally insane (or trading your stethoscope for a desk job, depending on your temperament) are excruciatingly tempting, believe me.

And then... There are the cover shifts. An untamed monster of stress and anxiety of demonic proportions. On-call days are mildly better in terms of stress levels, but only mildly.

In GP-Land, your days are filled with patients, one after another, and there's not much time in between to think. Just like working in ED, everyone that comes through your door is there for a different reason and although there's no way to anticipate what that reason might be, you've got to be prepared for it all regardless.

If you've forgotten something, or if something has slipped your mind during a consultation, you'll be lucky if you ever remember it because as soon as one patient leaves, another one comes in. And always, the most important patient is the one sitting in front of you. It's them who is entitled to your full attention, not the one that you've just seen, and you need to get it right every time.

If, like me, you're lucky enough to get awesome supervisors who love to teach and are good at doing it, there's also an element of stress that comes into play where you don't want to disappoint them. You want to do your best, be the best, and always be one step ahead of the learning experience. And often that internal pressure and stress is just as bad as the external ones that you have to deal with.

Being a doctor is hard.

So why so we do it?

Different doctors do it for different reasons. For me, and for most of my doctor friends (or colleagues, as those grown-ups say), we do it because there is nothing else that we'd rather do when we wake up in the morning (and sometimes late in the night) than exercise the privilege of helping our patients.

I suspect that the 'I want to help people' line is getting a little old these days at medical school interviews and thus probably isn't very likely to secure you an admission. However, I've found in my recent experience that, as cliched as it may seem, it's only cliched because nothing explains it better.

I watch myself and my friends go through so much hardship for this job, it's incredible. Day and night, week after week, we put aside our wants and our needs, push through our comfort zones, time and time again, for the sole reason that it is expected of us. The world expects it of us, and we expect it of ourselves. We do not question it, we do not settle for mediocrity.

Except for the occasional lazy intern, and believe me, there are unfortunately plenty of those going around making a nuisance of themselves. The rest of us though, are fairly hard workers.

And what makes it good, is when we get to the bedside of Mrs Jones or Mr Smith and we get to tell them in all honesty that we are doing the best we can to make things better for them. There is no joy in the world that's quite like the one you get when you gain someone's trust, and feeling like you want to do right by them. It is seriously empowering, and it gets you through all the rough days, every time.

And that is why I do it. That's my reason for waking up in the morning.

The way I see it, nobody likes being sick. But if my patients have to be sick, the least I could do is make the experience a little better for them, not just through medical intervention, but also through my interaction with them.

After all, in my short years through life and medicine, I've learnt that a little smile, a little laughter, and a little bit of humanity goes a very, very long way.

And, without a doubt, it is not only healing for the patient - it heals the physician as well.

We simply would not survive without it.