Doctor, or priest?

There’s always more floaters than time to anchor them to words. This, as with many posts, has been brewing (on cold drip?) for many months now. But I’ve marked it with a priority flag. Barely a month out and I’m already struggling to picture life in mainstream general practice or remember the stories that triggered this thought in the first place.

(On a side note, I suppose when you move clinics you wonder how the patients are doing. I haven’t much, except with the antenatals; many whom I’ve been seeing since their very first visit. I hope the little ones have hatched successfully. On my last day one patient gave me a hug and said, “aww, you mean, you’re not going to meet my baby?!” I recounted the story at home, then mum made the snide remark that I should just hatch my own, but that’s a scary thought.)

Is that medical

Many people demand medical certificates for work or welfare, without a medical condition, sometimes blatantly gaming the system for financial gain. But this occasion was memorable because it was the only time I’ve opened the door and informed a patient that we could not continue with the consultation.

The woman arrived more than half an hour late for a fifteen minute appointment. She was “fed up with working” and went on a one week holiday out of town. Now she was back and wanted a medical certificate to be paid sick leave for her days away. This was her first time seeing me, and she wasn’t interested to explore or manage any underlying issues. “The other doctor just writes a week off when I want some time off.” I gave her some options (me writing this certificate wasn’t one) and she started raising her voice. “What are you going to do for me? Nothing?! It’s a waste of time seeing you, you’re just adding to my problems. I’ll never come back to you again, YOU LOST ME AS A PATIENT.” Then she added, “I came late but had to wait. I shouldn’t have come on time anyway!”

To what extent (start of an essay question) is the employer-employee relationship, or a person’s unwillingness to contribute meaningfully to society, a medical issue?

The palliative care patient in his mid fifties with motor neurone disease. He always arrives in a fancy motorised wheelchair, skilfully navigating the width of the door by just a few nudges of his finger. Accompanied by the wife, who is ever impeccably dressed, positive and respectful of her husband’s independence (giving him plenty of time and space to talk for himself, and make decisions about his care). His mind was crystal clear, but his only functioning limb, the left arm, was becoming progressively weak. It shook too much for him to feed himself properly or hold anything. His breathing was increasingly weak as well. “Which state has voluntary euthanasia? I feel like a useless piece of meat.”

What hope can we offer in the face of protracted suffering and incurable disease?

The girl was about my sister’s age. She presented with numerous episodes of abdominal pain throughout the year. Nothing concrete on examination or investigations. So far she’s had visits to various doctors at my clinic and the hospital, including two inpatient admissions under surgery and paediatrics, with a variety of diagnoses including recurrent cystitis and pyelonephritis (negative cultures), appendicitis (had an appendicectomy), mittelschmerz, and possible dysmenorrhoea (started on the contraceptive pill). Later, it seemed like the episodes were related to school refusal and psychosocial issues. There was high tension between her and her mum, and between her parents who were separated. Out of nowhere she also mentioned being excited about her confirmation ceremony but complained that kids at her (Lutheran!) school were teasing her about being a “goody two shoes” Christian and going to church.

For a moment I wondered whether I’d have had more to offer if she was a girl in my youth group, rather than a patient at this clinic.

An elderly woman presented for a routine 75+ health check. She lived alone and independently – the closest family member was a sister halfway around the world. She was as well as could be. When we got to the part about her mood she says she didn’t feel down or depressed but wondered about life. “At this age I know more people dead than alive. I know it’s silly but I’m angry at them for leaving me.”

We certify deaths. Does that mean we are more able to grasp life and ageing, death and afterlife?

A woman came in for just a repeat script. But just a script is never as it seems. On tidying up the “issues” list on her file , she started talking about her pregnancy last year which ended in a termination. She was actually trying for a baby with IVF and went through the emotional rollercoaster, and financial cost, of several failed cycles. Soon after giving up, she fell pregnant spontaneously. Her husband was delighted but she was ambivalent because she had already given up by then. Then, during pregnancy she had severe hyperemesis gravidarum (nausea and vomiting) that wouldn’t go away or respond to treatment. She was waking up every one or two hours to vomit or dry retch, morning and night, and there was no relief from the nausea between the vomits. She was crying constantly. “I couldn’t handle it anymore,” she recalled, now with tears in her eyes, “people say you make the best decision for you at the time. But I don’t know. I feel guilty. I’m not sure I did the right thing.”

Can we acquit someone of their guilt?

Last one, and a strange one too – the patient turned the tables and started asking me all sorts of questions (which I largely refrained from answering). She presented under the guise of being up and down with her mood. After going through the standard questions, she didn’t have any symptoms of depression or anxiety. Then she jumped into her story, which was what she really wanted to talk about, given she was new to town and had no close friends to confide in.

She moved with her husband, who recently started a new job here. They had been married for over a decade and had several beautiful children. The couple had a fantastic relationship – “we’re soulmates”. He encouraged her to get out and about, and so she’s been hitting the gym. There she fell in love with her hot personal trainer, who was “the one” and everything she ever dreamed of. Alas, he felt the same way. She was even having “X-rated thoughts” about him (this information was definitely not from my history taking). “I feel terrible! What do you think I should do?” Not a rhetorical question. Then it got more personal – “what would you do if you were me? Are you married or in a relationship?”

Confessions. I’ve never been behind (or in front of) one, but I imagine this is the sort of thing that take place at a confessional. Does medicine offer moral and spiritual guidance?

Doctors are laypersons

“It is in reality the priest or the clergyman, rather than the doctor, who should be most concerned with the problem of spiritual suffering. But in most cases the sufferer consults the doctor in the first place, because he supposes himself to be physically ill, and because certain neurotic symptoms can be at least alleviated by drugs… We can hardly expect the doctor to have anything to say about the ultimate questions of the soul. It is from the clergyman, not from the doctor, that the sufferer should expect such help.” – Carl Jung

I chanced upon that chunk of Jung’s writing (he was sympathetic towards spirituality, but not a Christian) on a contemporary article about psychotherapy being a modern-day, secular form of priesthood. It’s not just about the expectations from society. Medicine has high expectation of itself too. We seek to help, and that’s wonderful. Caring and listening well is therapeutic in itself, and healthcare does offer pharmacological and non-pharmacological resources for a variety of psychosocial problems. Yet, in our eagerness to do good, to alleviate suffering, to provide holistic biopsychosocial-spiritual care, we can utter false assurance and smear balms (quacky ones) that do not heal.

As doctors, perhaps in our puffed up notions about our abilities, we forget that more often, we are the layperson rather than the expert. Consider, are you actually the best person to help with that “question of the soul”? I thought of it often, especially during the not-so-medical consults. It helped me to pause when I wanted to quickly cover my own inadequacy with empty words. I found it immensely helpful to remember that I didn’t, simply by being a doctor, have the upper hand in understanding social dysfunction, meaning of suffering, life and death, forgiveness and healing, love and relationships, amongst a myriad of other matters.

Where is your salvation

“Those things that you couldn’t do, and those diseases you couldn’t reverse, were left unspoken [in Ethiopia]. It was understood… In America, my initial impression was that death or the possibility of it always seemed to come as a surprise, as if we took it for granted that we were immortal, and that death was just an option.” – Abraham Verghese, Cutting for Stone (novel)

Not only is there a limitation to what areas medicine has claims to expertise, there is a limit of what is possible even within our own field. From time to time, people ask about it, being Christian and a doctor, as if these were mutually exclusive. Don’t you believe in science? Why do you need God?

I didn’t know what to say to the slowly deteriorating palliative patient, or any of the others really. Partly it’s my insufficient “life experiences”. However, my profession does not not have adequate answers either, nor can it offer salvation from suffering and death. Well, maybe for a time, but never all the time. Dr Cutillo in his book acknowledges the remarkable contributions of medicine. At the same time he points out the folly of putting excessive hope in medicine, in the place of God himself:

“No area of medicine can escape this sense of failure. Most obvious is oncology, when it involves incurable cancer. But rheumatologists cannot cure lupus, cardiologists still lose patients after a heart attack, neurologists must help people live with disability after a stroke, and even dermatologists see some patients die from melanoma. In every case there is a sense of failure, for both the patient and the profession… But science and technology are bound to fail if we ask them to fulfil promises of biblical proportions.” – Bob Cutillo, Pursuing Health in an Anxious Age

 

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The breath of life

Today is the day. I know because I receive automatic notifications of admissions to the public hospital. I knew anyway because I was reminded. Reminded to send a new referral prior to this date because the original didn’t have the required wording. Required wording – by law, or by the local service? I don’t know and neither did the coordinator on the other end of the phone. The omission was unintentional anyhow. But I was to amend to the precise wording, “I recommend termination of pregnancy due to psychological reasons”.

The teenage girl came in with her mum and boyfriend about a month earlier. The atmosphere in the room was tense as she went off to collect a urine sample. Mum was hysterical. The boyfriend stood behind mum (not enough chairs), occasionally brushing his fringe and slowly flicking his blonde shoulder-length hair to the side, before staring down at the floor again. He looked kind of stunned.

“Well, what did you think would happen?!” Mum snapped. They’d been together for a few months. Neither had a job. We discussed their options. Arranged tests and referrals.

That week another girl of the same age was in a similar situation. This was her second unexpected pregnancy, and she didn’t want to go through another termination. In the following week she went back and forth between wanting to go ahead with the pregnancy, and not wanting to. Her pregnancy was already quite far along and she needed to make up her mind. The latest was that she’d felt pressured by her boyfriend and his family to have an abortion, but he’s come around now. Is this a better outcome, or worse?

Pro-choice for the woman – how quickly that can become the-only-choice, if termination is seen by everyone around her as the only acceptable outcome. Including the health professional who is quick to put in writing, as I did, that termination is recommend for psychological reasons. How complete is the patient’s or their doctor’s knowledge about what benefits this individual in the long-term? Is what we want at the time always good for us? What if I don’t recommend? I suppose any colleague could refer her instead. What good, or harm, would come out of that?

Then there’s unexpected miscarriages. One woman had the slightest spotting, just once. Scans came back with an intrauterine pregnancy, but no fetal heart rate. Non viable pregnancy. This was the second time this year and she was devastated. Why does that even happen (not a medical why)? What happens to the fetus? Life ending so early, from something outside human control, is tragic. Equally so, is the deliberate act of ending a new life that could have continued.

There are reasons and there are circumstances. I acknowledge that I don’t know what they all are or what it is like to be in my patient’s shoes. Though I hope to make choices with a clear conscious before God, now and in the future, I can’t claim to know what my response would be should a difficult situation arise in my own life. Yet whatever our views are on abortion legislation and access, I think we can agree that the “demand” for these services – whether from unwanted pregnancies, medical conditions or other reasons – is not a good thing.

Reminds me once again that we live in a world broken and affected by sin. For unwanted pregnancies, I don’t just mean the choices of the woman and her partner (though in my view, we have personal responsibility regardless of our circumstances). Just as significant is the collective sin, of us as individuals in this society, in refusing to acknowledge God as creator. Believing that we are fit to define good and evil. That we only need to do what’s right for us, to be happy. Pretending that sex and childbearing are unrelated matters when we have modern-day contraception. Confidently asserting that we (rather than God) know best about relationships, sex, marriage, and even what constitutes the breath of life.

“As you do not know the way the spirit comes to the bones in the womb of a woman with child, so you do not know the work of God who makes everything.‭‭” – Ecclesiastes‬ ‭11:5‬

When it’s quiet – part one

It’s hard to write about med things without feeling bitter. So first, let’s get the bitterness out of the way. Even when the day to day is fine, it’s difficult to accept a career trajectory that feels forced upon you. I always thought people close to you come before work. But sacrifice come at a price. Maybe I’m particularly selfish, but I’m finding it a real struggle each day.

The darkest times have often been the minutes and hours before bed. I’ll spare you the creative details but I wrote a story years ago about the monsters Pain, Loneliness and their master Despair – who always visited “at night, when silence and darkness prevailed”.

Apparently I’m not the only one.

The woman in her mid fifties whose husband left her for a younger woman some years ago. “The kids adored the other woman and didn’t understand why I was so bitter. He took my frequent flyer points to take her to the US! He said I didn’t need them anyway. He died suddenly, at the gym on the treadmill. You know, impressing her. He used to say that no one would love me and if another man would sleep with me, he would shake his hand. I used to hear him taunt me, now I don’t. I’m still single and tried dating but it hasn’t worked. Work isn’t as creative as I’d like it to be. The kids are grown up and I flew over to visit them last Christmas. I was sitting in front of the telly eating by myself on Christmas Eve. They love me but I know they have their own lives now… I have a bedtime routine. Read a book, do some relaxation exercises. Then I would turn off the light but flip over and be wide awake. At night I think about these things. About my life, where it’s going, the big questions.”

Often it comes in the form of asking for sleeping pills. Another woman left her ex-husband and three kids back in her country for him. They used to call each other every day before she migrated, though the phone bills were very expensive. They’ve been together for the last two years but now he’s moved to a new job interstate. They still talked but were slowly drifting further and further apart. She kept thinking and thinking and couldn’t sleep.

Occasionally men cry during consults too. The tough looking bloke had workplace troubles and had been feeling down. “I have the missus and the kids. I don’t want them to see me like this. But when it’s quiet, I was thinking,” he grabs a tissue, “…what’s the point. It wouldn’t even matter if I wasn’t here…”

A patient I saw for spirometry results. They were normal. She attributed her symptoms to stress and grief. “It happened last year. He was so healthy, still doing fly-in fly-out months before he got sick. He had mesothelioma and it all happened so suddenly. There’s nothing there for me now. Oh I know I’m not the only woman to be widowed… I know I need to stand on my own feet. But I’ve done nothing, I’ve just been a vegetable. I came here to stay at my sister’s. I’ve only just started to cook a little. My sister and I have different cooking styles, I use a bit more flavour and my brother-in-law is thrilled. We go for walks. I tried a bit of adult colouring-in to relax. But at night when I close the door, I’m all alone and it’s really hard.”

 

 

 

Feeling better is hard work

The consult started with a box of tissues.

There was a lot going on. She struggled with mood issues on and off for a few years. But was in a good place until end of last year. She witnessed her father’s suicide when she was a little girl. Didn’t think about it much. Now her children were growing up and asking questions, and she started to think more about what happened. There were some ongoing family feuds amongst the siblings, and no one was talking to each other directly. Her husband was sub-fertile after chemotherapy for his severe autoimmune disease. They had been trying for another child for a few years, including several unsuccessful attempts at IVF. She felt like a failure.

For awhile now she was sad and teary all the time, but kept herself busy with work and home life. She was dubbed “cheery” at work because she tried hard to make sure no one knew how she was feeling. Not even her husband.

“Can’t you give me something for that? I just want to feel better.”

We talked a bit about goals and options. Discussed medications, what that involves, and the evidence of non-pharmacological versus pharmacological management. She tried the clinic psychologist a year ago and liked her. But stopped because she didn’t like having to talk about her problems. Or think about them. I thought about my own sadnesses, hmm (and hmm, should I be at work). I don’t have a view either way about antidepressants but it struck me then – the expectation that complex life problems can somehow disappear, go away, when you visit the doctor. I hesitated.

“I’m sorry to say this… but feeling better is hard work.” I said, gently offering the option of exploring her issues further, medications or not. I’m not passionate about consumer partnership. Even less so after editing some painful journal article on “co-creation” last year. But suddenly this idea that her life issues is something we treat, independent of her participation, became very odd to me.

The blurry line between medical and life issues (kid doesn’t like school, kid has preference for junk food, man has been cheating on wife, woman feels the need to clear her throat when she is nervous etc.) bothers me. The expectation of listening with a strong and perverse financial incentive to not listen bothers me too. Sometimes I wonder whether this line of work is for me, but I suppose it will have to do for now.

The people in hospitals

Colourful sunset near the hospital

View of a colourful sunset from the hospital

I had about half a year away from clinical work. This was the longest time away from hospitals since I started clinical school. In some ways, nothing much has changed – the paperwork, the unpredictability in workload, the conflicts. Yet, time away was not time wasted. I felt refreshed and more interested in the people around me, and their stories.

Doctors of all kinds

Several university classmates and co-interns from my old hospital. A registrar who quit surgical training after contracting a serious infection from a patient. A mini-property tycoon (buying a property a year since internship) making negotiations for his seventh investment purchase during our lunch breaks. Many studying and working including the ophthalmology registrar with a PhD who’s about to start another Master’s. The advanced trainee who had a baby and put her training on hold. Watching her doodle on the mindfulness colouring books in the most serene manner, you would never guess that she used to be an angry medical registrar. A few figuring out their paths or ones with several careers already – including an ICU / ED dual trainee who was a previous head of department in nuclear medicine. He also happens to run a free general practice clinic overseas several months of the year.

I hadn’t found many kindred spirits during these hospital years. A nice and unexpected aspect of locuming is discovering the range of characters in medicine, some with similar outlooks on life and medicine.

“Kindred spirits are not so scarce as I used to think. It’s splendid to find out there are so many of them in the world.” – from Anne of Green Gables

Patients of all kinds

People have interesting lives outside of their patient role. A patient in ICU said he was overseas often, working as a magician. In jest I asked whether he could do a trick and he said he was too sick. Days later he pulled out a deck of cards (and was out of ICU). He asked me to think a card, any card. Without me physically picking out a card from his hand, he “guessed” the card of the number and suit I was thinking of. He showed me the card which even had my initials at the corner. I’m sure he didn’t have time to scribble on it with a marker whilst I was watching him!

“Tell me, how did you do it?” And as expected, the answer was…

“It’s magic!”

Another time I saw a mysterious, black leather-bound notebook on a patient’s the bedside table. It belonged to the patient’s wife. She was an artist and it was her daily sketch diary – what lovely ink and watercolour sketches to brighten the most mundane day at the hospital!

Long love stories

Patients, especially the elderly, are surprisingly open with their life stories. A man in his eighties started talking about how much he was in love with his wife. He pulled out two photos of her from his wallet – one recent and one from her twenties.

“Isn’t she beautiful?” he said, admiring the photos once more. Holding back tears he said, “I miss her so much. She died last year and I’m so lonely. When you’re a young fella you can walk into a pub and make friends but it’s different now. Some women are interested in me but I don’t think I’ll get married again. We were one for over sixty years!”

“Do you think it’s worth getting married if you have to separate in the end?”

“Yes, yes I would marry her again. The love and companionship you give each other… and I was so in love with her!” He went on to tell the story of how they met in the military, how she dropped hints but he didn’t pick them up because as a new recruit he thought he didn’t have a chance.

He paused, then lowered his voice. “Mind you, we had our rough patches too. Once she caught me doing the wrong thing, you know. She called and said, ‘you come back to me right now because you’re my husband and we promised to be one. I forgive you.'”