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The Price of Medicine

When you come to your clinical years of medicine there is a big change to the way you think. You move from the classroom to the patient. Gone are the hypothetical “well behaved” patients and in come the group of people who are so varied that your text books may as well be set on fire. After years of lectures, textbooks, and exams, the students are plunged into the world of actual clinical medicine, where patients and their illnesses rarely go by the book.

We all wait for this moment but it’s hardly the crowning achievement it claims to be. Just wearing the white coat suddenly has people dump responsibility onto you. One that you aren’t prepared for. The learning curve is voraciously steep as students soak up clinical knowledge at an inhuman rate. You quickly learn just how much of your books were hokum and laughably naive and how “reality” works. 

The dark side beckons. The qualities of altruism, empathy, generosity, love, education and ethics may drive you to medicine but temptations abound. There are cheats, there are liars. You will be beset on all sides by those who would tempt you from your path. And it is a difficult and inhuman path. Your yearly reading material may be bigger than the total course material of other subjects. I look back at all the knowledge I acquired in medicine and all that I can say is “Fuck! Did I Do That? How the Fuck Did I Get This Far?”

And through it all is the crushing realisation that you do a thankless job. People automatically assume you are well paid and don’t do any work. That your job is easy. They don’t see the amount of effort that goes into making you a doctor because they think “Why? We Got Google!”. Never mind that those who Google DIagnose generally end up getting it spectacularly wrong, people will still not believe the person who has trained for years to learn the art of Medicine but will believe some idiot who calls himself a “Health Ranger”.

These erode you. They  kill the very person that you are. This leaves you jaded, filled with doubt, embittered. The debts don’t help either nor does the stress of working in medicine.

In many ways it’s simple for me. I don’t have much to worry about. People line patients up for me and I knock em down. There is something honest in working within this constraints because failures are “not your fault”. They are beyond your control. You don’t have the equipment, they don’t have the money.

In the developed world? The doctor who came to treat has to deal with the brutal reality of bureaucracy, drug interaction, patient idiosyncrasies, medical error, insurances, emergencies, hostile patients, stupid patients and violence. Nothing prepares you for the putrid smell of infected bed sores, the clanging of alarms and the bizarre language of the medic. Nothing prepares you for patients who demand you do something to help them but refuse to do what’s necessary to help themselves. Or the patients who attack you or swear at you or who do stupid things then expect you to fix them.

And the worst of all? We know we have no other skills. Medicine is so specialised you cannot do anything else. You cannot fail. Failure is not an option. You Must Win. At All Times. Like Charlie Sheen you cannot stop winning.

And the world changes in medicine. As soon as you settled down and learnt how the system works you are shuffled to a new post. Surgery, Medicine, Paediatrics, Dermatology, Ophthalmology, ENT, Obs/Gynae, Orthopaedics, Emergency. Each with a whole new set of patients with a whole new set of demands and a whole different system to work under.

And you aren’t just learning the science, you are also learning the art. How to walk, talk and smile. How to say yes and how to say no. How to work on your own and as part of a team. How to dress and how to dress down. How to identify patients who are “game” and deal with their conditions with a sense of humour and how to avoid pissing off the dour buggers who think doctors must be serious at all times because they saw it on the telly. How to identify the munkies (the accident prone) and the junkies (who claim to be accident prone but want free meds).

You will witness fear, anger, grief, humiliation, pain and suffering in both the patients and your fellow doctors and nurses. Most of this will not be noticed or will barely be acknowledged. Egos will clash since you are effectively dropping half a dozen smart people into the same room with a problem then expecting them to come to the same conclusion. Smart people may end up subservient to idiots and vice versa. Your hands may be handcuffed by bureaucracy where you know you can treat a patient but cannot because of a simple form. You will see the niceties of patient care sacrificed to efficiency, turn over and patient waiting lists. Your communication skills, manner and empathy may even turn up to be mere lip service.

And it’s expected to be lip service. I mean can you imagine genuinely feeling empathy for every single person going through your doors? I don’t know about you but my heart would break. You cannot expect anyone to do so. To immerse yourself in the suffering of others and feel it yourself and then go home like everything is fine. Empathy is a double edged sword in our line of work. Empathy will make the patient like you but it will hurt you. And yes, I have found myself getting jaded and not caring about those I treat.

Of course it is not all doom and gloom. You gain immense knowledge, and many find positive role models. After all, you find out who you really are in the dark and medicine is often pitch black. But if you can survive the plunge through this madhouse and walk away with your ethics intact, with honour, loyalty, love and everything that made you join medicine in the first place then you will be an excellent doctor. The way you see your patients determines how you treat your patients. 

And all this in a world where people still think we are charlatans, conmen and snake oil merchants. It is a thankless job.

If you don’t see the little things that give you thanks.

Today my moment was when I helped a man with two injured legs climb some stairs. No one else did. But that reaffirmed who I was and why I wanted to be a doctor. It reminded me that the sacrifices were worth it to squash the man’s ideas of medicine. That doctors are aloof and lofty. Not ready to roll up their sleeves and get dirty. Where no one was willing to help him a doctor did it.

And that did more for medicine than all the bandages on his feet.

Comments

  1. TGAP Dad says

    As a citizen (and resident) of the US, I have a deep admiration of the UK’s NHS. Here in the US, doctor’s compensation packages vary widely, with high-demand specialists (like cardiologists and surgeons) making extravagant high six- or seven-figure incomes, while PCPs (GPs in the UK) make a rather ordinary middle-class income.

    Could you give us a comparison between the UK and US health care systems from a doctor’s perspective? What would you like or dislike about each? What would you change?

    Love your blog!

  2. angharad says

    To be fair I think most professions have to deal with clients who ‘who demand you do something to help them but refuse to do what’s necessary to help themselves’ or ‘who do stupid things then expect you to fix them’ but I will forever be grateful to those people who choose necessary jobs which necessarily have horrible working hours while I enjoy the luxury of 9-5 and flexitime…

  3. says

    @mrp

    I think it’s just the reality of medical school creating a common experience.

    Empathy is tough. Generally I have no problem empathizing with patients, but it’s very dangerous when a patient does something that significantly diminishes your ability to empathize with them. They will get worse care if you don’t recognize the problem and address it, find them another physician, or just monitor yourself to make sure you’re not acting out of emotion. We were told in medical school to “beware the hateful patient”, not just because you hated them back but because in doing so they will get worse care. When you find yourself thinking those dark thoughts, pause, recognize them, address them, and make sure patient care won’t suffer.

    I lost my temper once at a patient, he was demanding narcotics at the nurses station saying he had 10/10 pain. He had known addiction issues and was cursing at the nurses. Also, no one has 10/10 pain and stands in front of a nurses station yelling. He was being a jerk. I told him he would return to his room and await the next scheduled dose of painkillers or I would cancel every single painkiller order.

    Now, it worked. He stopped cussing at the nurses, he was civil for the rest of his stay, but it was the wrong move. Even if he was exaggerating his pain he still did have pain. It would have been wrong to give him nothing. But I was just so pissed off that he was screaming at the nurse that I got angry at him. I’m glad he didn’t call my bluff.

    For the rest of his stay I had another resident handle his care because our relationship was ruined, any trust would be dead. That was a failure, and I learned from it, wouldn’t do it again.

    Now I would have told him to return to his bed, that verbal abuse of staff wouldn’t be tolerated, and that I would be in to examine him and see if his scheduled medications were adequate. It would be a disservice to the patient to simply give in and give them drugs, even if that’s easy and more peaceful, but you learn from the art that sometimes listening, performing a new exam, and showing you’re attentive goes a long way too. Still probably wouldn’t have worked. He was an asshole. But at least the doctor patient relationship wouldn’t have been damaged.

    @TGAP
    In the NHS physicians might not make as much in the US, but also consider we may carry half a million in debt when we graduate. 7 figures is also a bit of a stretch. Maybe a private-practice neurosurgeon might make 7, but that’s not where our excess costs are coming from. Excessive physician compensation is thought to be about 5% of excess US healthcare costs according to the Mckinsey report.

    And while I believe in universal healthcare, I dislike nationalized systems like the NHS. Give me the French or Dutch systems that are single payer but not government run. For one thing, government employees are impossible to fire, and you need to be able to fire people in medicine. Also, most qualified medschool applicants would not undergo 11 years of postgraduate training (typical – but some have more, almost 17 years in my case) to be paid like a schlub, while shouldering student loan debt. That would just be stupid. One of these things has to give. Either we get paid commensurate with that sacrifice, or government will have to shoulder the cost of our training and pay us during our schooling. And even then, years and years of training by some of the brightest students in the country still needs adequate compensation or the quality of applicants will suffer. While medicine is a calling, most will ignore the call if there isn’t some financial reward compared to equivalent professions like business or law (and we still finish way behind those two especially given the delay in our earnings).

  4. says

    @mrp – It’s an old article I worked on when times were “rougher”. I read the slate article just now and you are right. They read similar. I shall have to reword mine.

    I was kind of inspired to finish it after helping the guy climb a staircase.

    And I figure the burden is the same everywhere. My frustration at an uneducated populace is similar to the frustration of a western doctor to their uncaring populace. The issues may be different but the characters are the same.

  5. says

    Blog davvero interessante, peccato non sia ancora disponibile la versione mobile. Almeno io non l’ho trovata, infatti per leggere questo articolo sul mio telefono ci messo mezz’ora. Perlomento era interessante e ben scritto.

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