Dr Anna Choi is currently a first-year house officer at Middlemore Hospital, and also the PGY1 Rep on the New Zealand Medical Association (NZMA)'s Doctors-In-Training Council. After six years of medical school in Dunedin, she is enjoying exploring a new city and new hospital (despite being thoroughly outnumbered by Auckland grads!).

Follow Anna on her journey through The First Year as a junior doctor.

One of many Seasons: Fin

August 21st, 2011

I want to start off by congratulating most of the Trainee Interns on their job placements. For those of you who, for various reasons, are still waiting for an offer or have other significant personal decisions to be made, I want to reassure you that it will all work out. Trust me, I’m a doctor!

As I congratulate those who are nearing the end of their medical school journey (where I was a mere twelve months ago), it seems a good place to end THIS journey of mine. I never intended for this blog to go on for as long as it has. I feel blessed to have been able to encourage all those whose first step into doctorhood awaits. During my first three months on the job I couldn’t recognise the person I was, the person I had become, the person this job had made me. Yet like all things in life, like I have said from the beginning, “This too will pass.” My lowest was the truest low I have experienced but (in the fear of sounding trite) I am glad to have gone through it, if only so that I can tell you that I DID get through it.

Life is good. With my two busiest runs, General Medicine and General Surgery, behind me, I have just finished what turned out to be a surprisingly fun Geriatrics attachment and now have three weeks of leave! I make adult money, and at this moment, I am getting paid for being home and sleeping in. There really are upsides to becoming a “proper” adult! Best of all, reflecting on the year nearly gone, I have grown so much in the doctor that I am, the doctor I am continuing to become.

My favourite part of my First Year has been slowly developing my own style, my own flavour, to this work. The amazing thing is that we can choose the kind of doctor we want to be. With what adjectives do I aspire to be described by those around me, by patients, their families and by other staff? Loving, joyful, patient, kind, gentle, efficient but thorough, confident but humble… I believe in the power of a human touch, in a hand that is held; I believe in our position of power and, with that, the importance of a lower bedside vantage point; I believe in the importance of communication, for, much like a tree that falls in a forest with no one to hear it, can healing fully occur without a patient understanding what we have done for them? Regardless of what speciality we enter, each of us has the power to choose what kind of doctor we will be at the most fundamental level. And this starts in our First Year.

What memories will stay with me as I look back on this experience? My first long day when I called up the senior registrar to ask what I should do about a febrile intellectually disabled patient who refused to let me examine him. (The forty minutes of angst leading up to the call, only to get a reply of, “What do you expect me to do about it?”) Holding the Resus pager once when it went off thirteen times, physically spanning the entirety of Middlemore! Walking across the bridge over the train station every morning, staring out at the train-tracks fading into the distance and wondering how far away in the world my credit card could realistically take me. Standing next to Mr A in Theatre, holding his hand as he was put to sleep, smiling back at his last sweet smile to me… and the heartbreak I felt when I heard of his arrest the next day. The endless faces of the LOLs (= little old ladies) who shuffled their walking frames out of my ward with a smile and a wave, and the “eureka!” moment that followed when I realised the Laws of the House of God really are ALL TRUE.

I survived my First Year. It was truly touch and go there for a while, but I made it.

And so will you.

It is the ultimate Rite of Passage for us doctors, and at the end of your First Year you too will have a repository of memories – funny, intense, heartbreaking, breath-taking memories – that you will replay in your mind like scenes from a movie and think back to with fondness. Even the shitiest of moments. Because they all played a part in making you the doctor you are.

And as your first year comes to an end you will start to realise that the world truly is your oyster. The advice I want to give you is this: grab the world by its metaphorical kahunas, get creative, and make it your own. There is so much freedom in second year. You can do research (part-time, full-time), join the armed forces, do a diploma or Masters or a PhD (for those of you who can stomach the commitment), travel (but come back!), go to Australia or the U.S. to work (but come back!), volunteer, apply for a training programme, write a novel… or all of the above!

Earlier this year one of my General Surgery consultants shared with me a quote by a famous Theologian, F. Buechner, that has stayed with me. “A person’s vocation – their calling – is the intersection of their greatest happiness and the world’s greatest need.” In our profession there is a need for everything, so the question that remains is, what is your greatest happiness?

Good night, and good luck.

From my heart to yours,
- A

Acknowledgements: Oliver Hansby, for the idea; James Tan, for breathing into it life; and NZMSA for graciously allowing my words to be immortalised on their slice of cyberspace and, with that, to be shared with the eternal Void.

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Dr Dre is right: we all need a doctor

July 31st, 2011

It’s a universally accepted truth that doctors make the worst patients. We struggle to exist in the healthy area under the bell curve, instead, resting in either extremes of “Closet hypochondriac” or “Call me Mr Invincible.” Maybe it’s an occupational hazard, one that is, to some degree, inevitable, because we separate ourselves from our patients everyday. They are sick, we are not; they need help, we are fine. We live out the days of our lives in the hospital and rather than associating it with hurt, suffering, and pain (as most people would do), the hospital is our playground.

I have been blessed in my life in that I have never really had to deal with illness or suffering, in myself or in those I love. The two times I can remember seeing a doctor during medical school was once to see if anything could be done for my perpetually frozen toes (Dx: Dunedin), and once during fifth year when I was sure I was anaemic given how tired I always was (Dx: final exams).

So what’s with all this “Get a GP” business everyone seems to keep going on about? Apparently, “Doctors need doctors too!” Really? Do we? Not only that, but apparently, it’s not good for us to treat our loved ones, even if it will save them forty dollars at the GP. If I’m being completely honest, I had never seen what the big deal was. Two recent events, however, has me converted: Oh, Medical Council, I concede, you are right.

One of the first things they recommended during our Orientation week was that each of us should be registered with a GP Practice. Being new to Auckland I didn’t really know where to start so I told myself “Future” Anna could figure it out once life had settled down a bit.

Seven months later I found myself in survival mode, desperate to see a GP, but with nowhere to go.

Naturally being a morning person sleeping during the day is not something I have done much throughout my life, and this year I have come to realise I have an all-resistant circadian clock (black-out curtains, eye mask, ear plug – the works). Middlemore medical nights which are notorious for their constant deluge of jobs meant no sleep during the shift itself, followed by no more than three hours broken sleep during the day. Sympathetic to my plight many house officers and registrars offered up various suggestions, pharmaceutical and otherwise. But I was hesitant. I thought if I could just get through the week I would be fine. By the end of my third shift, however, I was broken. I now understand why sleep deprivation is such an effective method of torture.

Which brings me to my drive home at eight in the morning, knowing I couldn’t survive another shift in the state I was in, and I was desperate for help.

I drove up to the nearest GP Practice to where I lived. I saw that it had just opened and walked in to ask for the next available appointment (enrolling in the process!). But the battle didn’t end there. Sitting in the waiting room, I fought the impulse to leave: Was I really “sick”? Did this even qualify as a “Presenting complaint”? I was pretty sure there was no mention of my current ailment in Harrison’s Principles of Internal Medicine.

At the end of the ten-minute appointment my GP wrote two sentences in his notes: “BP 105/60. Heavy night shifts as first year house surgeon.”

I laughed. It was nothing life changing. No miraculous healing. Yet, somehow, leaving his office I felt surprisingly… better. It wasn’t just because of what he offered for my problem in that moment, but, rather, a sense that I was now no longer alone in holding responsibility for my health, and that there was some sort of accountability, documentation, and safety net I could rely on over time. A fresh, objective set of eyes, working in conjunction with an experienced medical brain. If Joe Bloggs down the street is entitled to this (also know as healthcare), are we not also? We pay enough taxes certainly!

Along those lines, a couple weeks later my mum – a fierce four foot nine woman who has never been sick in her life – had sudden onset of severe vertigo. My dad, distraught, didn’t know what to do apart from wanting to call the ambulance. My mum, not wanting to spend the fifty dollars, refused, but in saying that, I had never seen her look so scared in my life.

How many times during on-call shifts had I been paged about a patient “complaining of dizziness”? Yet as I knelt beside my mum lying in bed, taking her pulse and flashing a light into her pupils, my own heart began beating exponentially faster. Vitals signs being vital, all I wanted was a way to take her temperature and measure her blood pressure (oh, the things we take for granted!). After doing a neuro exam (which was, objectively, unremarkable), I still had no idea what to do. All along I knew in my mind it was probably “just” labyrinthitis but was I sure enough to call it? And even if I was confident to make the diagnosis, what did I have to offer to this tiny suffering woman who gave me LIFE!?

The GP listened for two minutes, asked a few questions, performed a Dix-Hallpike manoeuvre, and then declared that what my mum had was, indeed, viral labyrinthitis. He gave us a script for stemetil and it was all over. Just like that.

Again, it was nothing life changing. He confirmed what I had already been thinking. Yet upon leaving his office I felt as if a ten-tonne load had been lifted off my heart. An objective, experienced medical professional deemed the cause of my mum’s suffering as a simple self-limiting viral illness. What’s more, he now held the responsibility for her diagnosis and treatment… not me. It’s not that I don’t want any responsibility in the well-being of those I love. If I disagreed or had reason to worry, I can’t see myself sitting passively by. But I understand now how you can lose your objectivity when it’s someone you care about; I was surprised how quickly distressed I became, seeing my mum so upset, because her suffering became my suffering, and all I wanted was for it to end.

An important part of growing into this new role of being a “doctor” is knowing when we need to relinquish it to some degree. This is easier said than done because like I mentioned earlier, being a doctor is not like a coat we can take on and off, but rather, a new skin we grow into. With that, we’ll never be able to fully separate ourselves from our identity as a doctor. But in those moments when it comes to our own health and well-being, and of those we love, it’s important that we recognise that we are only human. At the end of the day, you are right Dr Dre.

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A heads-up for the ladies: the challenges of being a female house surgeon

July 15th, 2011

In my first post I mentioned how some of the issues I faced in my transition to doctorhood may have been specific to my situation, my personality and my gender. I want to take a few minutes now to talk about the latter: the often overlooked, unexplored experience of being a woman and a house surgeon. As a woman I have a vague sort of equal parts appreciation and equal parts guilt when thinking of the history that brought me to where I am today – appreciation of the pioneering women who went before me when they were literally one in a hundred, along with a guilt that I am taking for granted how comparatively easy I now have it. In saying this however I cannot deny that there remain a few difficulties unique to being a female junior doctor even today.

I will preface the following with a disclaimer: I love being a woman. Despite lacking the conviction of a true feminist I am certain that the inbuilt dispositions of women bring an invaluable dimension to the provision of healthcare. I may be generalising to some degree because an individual’s personality ultimately plays a big part, but there is something to be said about the beauty and emotion of a woman’s touch.

Herein lies my Catch-22.

Being a house surgeon requires me to make decisions about others, enforce the decisions of my bosses, and with all that, advocate for my patient’s wellbeing. To complicate matters, I have little control over the larger context in which I am working. I am but one cog in a very busy machine in which (literally) a thousand different agendas are being pursed by thousands of different people everyday. Therefore in order to do my job I must be firm, direct, clear, fast and efficient, and I must prioritise and delegate. This is the same regardless of gender. However allow me to propose two key aspects of being a woman that can make this job trickier than our male counterparts may find.

The first is related to the complexities of female-female dynamics. For you ladies reading this, take a moment to cast your mind back to your primary school days. Amidst the sticker books, Spice Girls choreography and roly-polies, you may recall the birthday party dramas. “You’re invited to my birthday party!” ‘You’re NOT invited to my birthday party!” “She’s MY best friend!” “No, she’s MYYY best friend!” I do not claim to be a social anthropologist, but from personal experience and reflection I have found that female-female interactions tend to be multi-layered, while male-male and (professional) female-male interactions tend to be much more straight-forward. And when you’re working alongside female nurses and other female health professionals, add to the female-female dynamic differences in age, medical knowledge, personalities and conflicting agendas, and you will find issues can arise.

Sometimes it is misunderstanding and/or misinterpretation of what you have done or said. (For example, you might explain to somebody as part of your professional duty that what they have done is potentially very dangerous for the patient and by doing what they did they assumed responsibility had something gone wrong. Yet what they hear in this explanation is an attack on their person. Whoa, you think to yourself, that was unexpected.) Yet regardless of why, ultimately it can feel like there is only a very fine line between being a firm, direct, clear, fast and efficient, prioritising, delegating house surgeon, and being perceived by others as bossy and demanding… while our male counterparts are admired for their “confidence” and “professionalism” in doing the same thing.

The second aspect with which I have struggled is the way this job often tries to rob me of my femininity. I admit, that may sound a bit cheesy or superficial, but I am at the end of the day only human, and I, as a woman, like to feel like a woman… and not a tired, smelly, bossy-and-demanding IT, unfazed by rectal exams and urinary catheters. A couple of weeks ago I was doing a string of medical night shifts covering eleven wards on my own for eleven hours. Getting a total of maybe three hours broken sleep during the day and absolutely none during the shift itself, I felt and looked like the undead. As I stood in the drug room at 2am setting up to do an IV leur round, I could feel the wrinkles slowly forming around my eyes.

A single woman in her mid-twenties, I found myself asking into the Void, “Is this really worth it?”

I am still waiting for an answer.

To my future female colleagues, we are privileged to be in this position. Our right to be here was fought for and now, believe it or not, we are the majority. Yet there are still aspects of the job that demands things from us it does not from our male counterparts. I have yet to figure out a solution, or even reconcile myself to this inevitability. I have had a few tricky, unexpected, and even horrible experiences, but with all that I have little to offer other than a heads-up.

But if you’re ever in Auckland get in touch — we can have a brainstorm over coffee and continue to make Beyonce proud.

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Paddock Theory

June 26th, 2011

It’s amazing how six months can seem to fly by when you’re looking through the retrospecto-scope. I have been a doctor for over half a year now. A part of me remains in disbelief at that fact, but surprisingly, it’s only a small part. That new-skin feeling I mentioned before has largely faded to the point that being a doctor now feels… ordinary.

My journey thus far parallels my journey with the rectal exam. Yes, you heard me right, the rectal exam.

I still remember my first rectal exam. A bewildered and do-eyed fourth year at Urology Outpatients Clinic, the Locum Urology Consultant asked me if I had done a rectal exam before. No, I replied. After briefly talking me through the process, he asked his next patient if I could do the examine as well. With the patient bare from the waist down and the consultant looming behind me I stood there with my gloved finger up another human being’s bottom and all I could think was, “HOLY SHIT [no pun intended] I HAVE MY FINGER UP THEIR BUM!!!! OHMYGOSHOHMYGOSHWHENCANITAKEITOUT?!” “Do you feel the prostate?” My consultant asked me. “Uhhuh,uhhuh,” I replied, having no idea what was what, just wondering when it would all be over.

I never had many opportunities to do rectal exams through medical school. It’s impossible to overcome the awkwardness of asking a patient (after a “proper doctor” has already examined them), “Do you mind if I have a go?” During my General Surgical rotation last quarter, as I talked to my Physician’s Assistant and friend about this lack of confidence, she told me something that, quite frankly, changed my life. “Rectal exams are easy! This[lightly tapping her chin] is normal, this [lightly tapping her nose] is BPH, and this [lightly tapping her forehead] is cancer.” Since then it has required conscious effort to dull down my enthusiasm for rectal exams during lunchtime conversation. My enthusiasm could be taken the wrong way I guess, but why it makes me so happy is because for me it reflects my growth as a doctor these six months past.

Becoming a doctor does not happen overnight. When you first start out it feels arbitrary because, it is. One day you’re a student (something you’ve become fairly good at) and the next day you’re a doctor. Yet let me assure you now, it is not an overnight process. It is only now, after six months, that it no longer feels as strange, I no longer feel as scared, and life no longer feels as overwhelming as it once did.

This past week I attended a workshop for first year house officers on Wellbeing. A small group of us sat together and learnt about practical ways of dealing with stress, shared personal experiences on what we’ve found difficult, and learnt how to apply the “theory” of looking after ourselves to our everyday lives. What really stood out for me during this workshop was the importance of setting boundaries at work.

The unique pressure of being a house officer is that you are the first-line of defence. When on call, you are the filter of what is the truly “sick” sick patient verses the “well” sick patient. During the day, you are the one “others” (i.e. non medical people) go to with any concerns or issues, the filter of what is relevant verses what is irrelevant. And always, you are the hands and feet of your team, the one who ensures the decisions that get made are followed through. That is MORE than enough to keep you busy, believe me. And thus the importance of setting boundaries between what is your problem and what is not. It is easier said than done when first starting out because at that point, (a.) you’re not sure what SHOULD be your problem, and what is not; and (b.) you tend to lack the confidence to be politely assertive. Yet I’ve come to learn this skill is so key to not only doing the job well, but to your own well being.

Discerning what is your problem comes with experience. Unfortunately, this will take time. But as you start to learn don’t be afraid to be politely assertive with those putting pressure on you. Ultimately your “allegiance” lies with keeping your patients safe, well, and alive. We can so easily get distracted, pressured, or way-laid by those around us and by momentary situations that we lose sight of the end-game. Sometimes keeping that allegiance will feel thankless: you bust your ass for sixteen hours, juggling four or five wards, and as you leave the nurses might make a snide remark about how inefficient house officers are, not realising you were tied up with a sick patient elsewhere. You’re reaching your Day 12 and a patient’s family is angry at the lack of doctor face-time they’ve had this week and the fact that their scan is delayed once again. You’ve been leaving late every day that week to ensure all the jobs are done, and then your registrar chastises you for being five minutes late that morning, with no mention of your coming in early for the past two weeks.

These are but a few examples. Yet at the end of the day, the not-so-nice nurse who does not understand the bigger picture is not your problem; the inpatient family should not be blaming you and if they are, you owe them professional courtesy and the rest is not your problem; and as for the angry registrar with impossible demands, remember that you are an employee of the DHB and if you’re busting your ass, it shows to those around you. Have faith in that.

Don’t get me wrong. I’m not advocating being mean, I’m not saying don’t listen to those around you whom you work with, or to avoid frustrated families. Simply that, most of us are by nature overachieving pleasers – we work hard to please others. Just don’t forget that a part of growing as a doctor is growing in our professionalism and that involves being aware of what our role is, what is expected of us, how to do our job safely, and with all that, how to set professional boundaries whilst still respecting and working alongside other health professionals and our patients.

It’s okay to say, “I’ll do it later, let me deal with x, y and z first.”

It’s okay to say you’ll talk to the family tomorrow because you talked to them yesterday and could you please stop paging me about it because we’re still on post-acute rounds.

And it’s okay to say No.

Especially when you know it’s not right to say Yes.

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And above all else, do no harm

June 1st, 2011

It’s 4.22am at Middlemore Hospital; my second set of nights this year. At a few tertiary hospitals around the country if your first run is general medicine you will start nights after three months. My first set of nights was back in March. I quite enjoy doing nights. The chaos of the days is replaced with a quiet calm and you have the chance to be an “independent practitioner” (which is both freeing and challenging).

The idea of doing nights can be scary. Now having done them, I think what scares us more than anything else is the idea of being on our own. During my elective I met a young doctor who spent a year in rural Ethiopia with Doctors Without Borders. From the experiences he shared with me it was obvious that for days at a time he was literally the only doctor at his ‘hospital.’ But New Zealand is not rural Ethiopia. If you take a moment to think about it you’d realise we are never alone. There is always help we can ask for. The part that scares us as new doctors is, how do we know WHEN to ask for help? It’s a fine line between being safe verses being unfiltered in our asking for help to the point of incompetence.

It’s hard to articulate, but there is a gauge inside each of us, a gauge in the metaphorical pit of our stomach that screams, “This is out of my depth!!” This gauge will grow with time, confidence, and clinical knowledge, but the actual feeling remains the same. Let me present you with the following three situations in which my gauge was put to the test recently.

The sick patient who looked well

Around half past midnight I got called from a nurse about a patient complaining of chest pain. Vitals? Tachy but stable, they replied. ECG? Doing now. Oxygen, GTN, morphine, I’m on my way, I replied. [Lesson 1: Never leave a chest pain unvetted.]

Upon entering the room the patient had a negative “end of the bed” test (meaning, she looked completely well from the end of the bed). Furthermore, the first thing the patient told me was that the chest pain had occurred over an hour ago and had since completely self resolved. No more pain.

No more pain? I repeated, quietly reassured.

At that moment the nurse walked in with ECG in hand and told me that they thought we should make a ‘888’ Medical Emergency call-out. To put it in context, at my hospital if a triple-8 call is made the full cavalry of medical registrar and house surgeon, ICU registrar and specialist nurses, would arrive within a few minutes. Nervous about making my first call, I hesitated. Was this nothing? The pain didn’t sound beautifully cardiac, there was no radiation, and it had self-resolved. The patient was completely non-distressed. Was this just reflux in the middle of the night? Was I disturbing busy registrars, all for nothing?

Do I? Or don’t I? Do I or don’t I? A rare moment when both Google and Wikipedia can offer you no solace.

All these thoughts raced through my mind in a flash. The nurse showed me the ECG, which was tachycardic, but before I had time to process anything else they said to me, “I’m going to call it.” [Lesson 2: Vital signs are vital. Never dismiss an acute change and/or continuing deterioration in one of the vital signs.] Okay, I replied, as I started to look more closely at the ECG in my hand.

Fast a-fib. In a patient whose systolic blood pressure was normally never higher than ninety.

Whoa.

Within minutes the cavalry arrived, an organised chaos followed, and a long discussion about where to go from here in light of the patient’s background. Ultimately the decision was made to start the patient on an amiodarone infusion under the watchful eye of HDU.

I waved goodbye to the patient as they were wheeled out of the ward an hour later and thought to myself, “If in doubt, Anna, call it out.” I don’t know what would have happened had the nurse not decided to call it when they did: would I have made the call myself, or spoken urgently to a med reg for advice? If the latter, would I have done harm to the patient by taking that path instead of making a triple 8 call? Was taking her to HDU the best option for her? Would she have deteriorated if we hadn’t?

I am reassured by the fact that even the medical and ICU registrars were uncertain of what the best course of management was for this patient, that in the end it required a multi-specialty discussion to come to a decision. The meeting of great minds. It WAS beyond me.

Never leave a chest pain unvetted. Vital signs are vital (and they are your best friends in triage on a busy on-call night!). And most importantly, if in doubt, call it out. The worst thing that can happen by making the call then realising on retrospect that you probably didn’t need to, is you may feel silly for overreacting. The worst thing that can happen if you DON’T make the call and the patient truly is deteriorating is, they could die.

Which would you rather have on your conscious as you walk out the hospital doors on your way home?

The sick patient who looked sick

A few hours later that same night I got called about another chest pain. The patient was someone I knew very well as they were my regular team’s longstayer. Initially admitted to ICU with multi-organ failure, they had made a good recover over the past month and a half and was now on the yellow brick road to the bountiful land of Older People’s Rehab.

As I entered the room my own heart quickened. Over the course of the night their systolic blood pressure had slowly been declining, and they had a positive “end of the bed” test. They were in pain and they were distressed. What’s more, they had the same look on their face as an elderly not-for-resuscitation patient I had watched literally die from a myocardial infarct earlier that week.

I froze. Everything started moving in slow motion. It took me what felt like a lifetime to tell the nurse to give some IV morphine, LIKE, NOW. And as my brain was processing what was going on around me, that inexplicable gauge in the metaphorical pit of my stomach screamed, “THIS IS OUT OF YOUR DEPTH!!!” I knew this patient could potentially be on the precipice of death, and I wasn’t ready to deal with this on my own.

Call it, I told the nurse. And I had no regrets.

In the end it wasn’t a myocardial infarct but septic shock. Yet much like OSCE exams, getting the final diagnosis right is only one mark out of twenty. The rest is your process.

Never leave a chest pain unvetted, vital signs are vital, and if in doubt call it out.

The first year doctor who failed an arterial blood gas FIVE TIMES

Yes, I am that first year doctor. And yes, I failed an ABG five times… on the same patient… at four in the morning.

The job was handed over to me by the evening on-call who wanted to rule out pulmonary embolism (PE) as a cause of the patient’s acute drop in oxygen saturation. The patient was otherwise well, all their other vitals were normal, and clinically their risk of PE was very low.

A frail elderly patient, tortuous superficial veins coursed over their bounding radial pulse. To make matter worse the patient was a squirmer, unable to sit still as I slowly navigated the needle down their wrist. After three unsuccessful attempts at midnight, I paused and asked myself, “How necessary is this ABG?” I wasn’t all that convinced they were at high risk of PE, their saturation had improved (though still not ideal), and I was reassured by their Wells score of 1. So I explained all this to the patient and made a deal with them: if their vitals remained normal overnight I would hold off on further attempts of this blood test.

At four in the morning I received a call from the patient’s nurse telling me their saturation had dropped again as well as their blood pressure. Still not convinced it was a PE but unable to justify holding off on this blood test any longer, I took a deep breath in and grabbed hold of my lady balls. What was it that Beyonce said? “If at first you don’t succeed, pick yourself up and try again, pick yourself up and try again.”

Apologetic but adamant, I conveyed to the patient the importance of this blood test in the context of what was going on. They reluctantly agreed.

Gloves soaking with sweat. Two more failed attempts. Wow. A new low. What a horribly mean, mean doctor I was. And then that gauge in the pit of my stomach started to whisper, “I think you are now out of your depth.”

What to do, what to do… One upside of doing general medicine as your first run is that you get to know the medical registrars. And, luckily for me, I knew one of the registrars working that night. I called them up and explained the situation I was in, sheepishly, with my tail between my legs. But they were so lovely; they were up on the ward within a few minutes, talked me through technique, and then they did the ABG on the patient oh-so slickly.

RESPECT.

An hour and a half later, as I was counting down the minutes until the end of my shift, I got a call from my surgical registrar.

“Hey Anna, can you do me a favour for a medical patient I’ve just reviewed who I think is obstructed?”

“Sure thing. As long as it’s not an ABG,” I replied, half jokingly.

Pause

“It’s an ABG,” the registrar stated. “The medical house officer’s just done one but it’s totally venous.”

“You’re serious?” I asked.

Pause

“Okay, yup, I’m on the way,” I resigned.

Did I have a choice? I shook off my five failed attempts, took on board the advice that the medical registrar had given me earlier, and went into that room like I freakin’ owned ABGs. Fake it till you make it, right? And you know what? Perfect arterial sample, first pop.

Medicine is both a science and an art. And sometimes to do no harm will mean recognizing when you are out of your depth and need to ask for help. That’s how we learn, that’s how we grow, that’s how we become confident. Never forget the oath you took to — above all else — do no harm.

And on that note I want to finish this entry by acknowledging all the medical registrars at Middlemore Hospital. They are, both as individuals and as a group, the most amazing, gracious and smart people I have had the privilege of working with. Middlemore is blessed to have them. And I am blessed to have worked with them. Thank you.

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For you, Mr A

May 18th, 2011

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‘Discharged to Mortuary’, Part 2: A quiet revolution

May 2nd, 2011

Once upon a time, 250 medical students sat in Colquhoun Lecture Theatre on Great King Street, Dunedin, listening to whom I presumed to be a psychiatrist talk about Stress and Distress. Spewing figures and facts she highlighted that we as a profession were at a higher risk of developing depression and alcohol dependence, and generally having a lower quality of life. She then went on to speak about the cluster of house surgeon suicides that occurred in New Zealand in the mid-90s. “How sad,” I thought to myself, before going on to ask my friend what we were doing for lunch that day.

I’ve always done med school well. Not that I was a Distinction student (far from it), but I could always manage. Sure I had my ups and downs, runs I did better on compared to others, but I don’t recall ever feeling out of my depth.

That is, until week six of work.

What I have to say next isn’t easy. As I commit these thoughts to paper I begin to have a physiological response. A part of me wonders if by admitting that I struggled I will be disadvantaged in my future application to the surgical training program. The last thing I would want is for the selectors to read this and think, “That Anna struggled with first year? We can do better than her. This other applicant is just as qualified and they never struggled.” It sounds silly and I am trying to convince myself it would never happen, but a part of me still wonders, and will always wonder… and worry.

That, in a nutshell, is the stigma against stress and distress which we doctors create for ourselves and continue to perpetuate. That is the culture of medicine. And if History has shown us anything, the only way to change a culture is by a grassroots, bottom-to-top, quiet revolution.

This is the account of my Rock Bottom.

This is my revolt.

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After the string of patient deaths around Christmas I found myself heading into yet another 12-day stretch. At around the same time our team was caring for a young patient who, from a medical point of view, did not have any problems. However in the world of modern Western medicine in which we practice there was one potential serious diagnosis we had to rule out prior to discharging them home. To do this, a specific test was required, a test which kept getting delayed.

And when patients want to voice their frustrations to “The Team,” it will most often fall on you as the house surgeon to bear witness. In these situations de-escalation is key. Yet conflict resolution requires patience and an investment of time. Neither of which is easy to come by in the unforgiving and insanely busy wards we work in.

It is in this context which I found myself dealing with this particularly difficult patient. And with each day that passed I began to dread work more and more. This dread was strangely different from anything I have ever felt before. It was, quite frankly, a sense of impending doom. No, I wasn’t having a myocardial infarction. But each morning as I walked through the sliding doors of the hospital my world seemed to flick into slow motion and I found myself begging my Maker. “Please, don’t make me go back in there. Please, I’ll do anything. I can’t go back there.”

This Pavlovian response only seemed to get worse. The days dragged out. There was no ounce of joy in the work. Each day only felt like a bigger failure than the day before. My desperate coping mechanisms du jour began to fail one by one. And I found myself wondering why I kept coming back to do something I had absolutely no desire to do.

If insanity is doing the same thing while expecting a different result, then by that definition there was no doubt I was going insane.

The physical exhaustion drained me of my psychological and emotional reserves. Under normal circumstances I could easily shrug off the stinging words of a radiology registrar telling me I was incompetent. But when I was already running on empty every moment felt like I was walking on an emotional tight rope, and all that was required to topple me over was a whisper.

Being on call that weekend was unimaginably horrid. The workload, for one house surgeon, was impossible, and I was barely holding on by the tips of my fingers. After a post-acute ward round that lasted until noon and dealing with one particularly sick patient, it was already two thirty before I had a chance to sit down, let alone check the five pages of “Weekend on-call house surgeon” jobs left for me by my peers. I grabbed a sandwich then went to another ward to hide. All I wanted was a breather. A moment to myself to collect my thoughts. And as my thoughts were collected it dawned on me that I was completely shattered. At that moment one of the medical registrars happened to walk by. I’ve never been good at hiding my emotions and he must have noticed something was wrong because he asked me how I was doing. With that, I couldn’t stop myself from crying right there and then. [Yes, again with the tears!] This lovely registrar forced me to leave the ward for twenty minutes, but not before taking my pager and half of the on-call house surgeon job list. He was still helping me with jobs at six in the evening (despite his shift technically finishing at four).

No amount of baked goods could ever convey my gratitude. All my life, I will never forget his kindness.

I was back on Monday for Day Eight and, with that, back to being the punching bag for our impossibly demanding patient. This patient continued to flip-flop between being angry and distraught, placated only by my sitting next to them in silence, holding their hand for thirty minutes, and apologising for the situation they were in.

It was exhausting. Emotionally draining.

And with everything else that was going on I was on the precipice of burn out. I needed a day off. I went to the RMO Office, burst into tears, and explained to them what was happening. “Oh yes, we’re so sorry to hear that. Of course, we’ll try out best to give you a day leave,” only to later receive an email with the subject heading, “DECLINED.”

That was it. The final nail on the coffin that was my life.

I have never known what hopelessness felt like until January 2011. I have sat alone for thirteen hours on a hard metal bench in an empty airport in Senegal in West Africa surrounded only by French speaking African soldiers welding machine guns, with no food or flushing toilet and no sleep for twenty hours, with my flight query indefinitely delayed… yet even then, there was Hope.

I could never take my own life, as I personally believe that my life is not my own to end. But I understand now what could bring a person to that cliff-edge. More than sympathize, I can now empathize. When you cannot see any glimpse – not even a flicker – of light at the end of the tunnel; when the more you move forward, the longer the tunnel seemingly becomes; when you cannot envisage a time when things will be different… when all that exists is the blackness of Now, with no hope for tomorrow.

These are the thoughts that bombarded my head as I succumbed to Rock Bottom.

A few days later I picked up my friend on the way to dinner and as I pulled out of the driveway I broke down. I screamed, I raged, I cried; everything I had been holding in, the exhaustion, the frustration, the dragging heaviness of my heart, I let it all out and with that, let it all go.

More often than not, Rock Bottom sneaks up on us. It is a gradual build-up of seemingly insignificant ‘little lows’ which we keep hidden to ourselves. Your ‘little lows’ may be different from mine. They may build up faster or slower; maybe your week six will be pretty darn sweet. But the one message I want to leave you with as you head into your first year as a doctor is this: we ALL struggle. It is not just you. Those second years around you, those registrars, your consultants, each of them have gone through what you are going through now, no matter how on-to-it they may seem. We each of us have had those lows. We’re just not good at talking about it. Us Kiwis are so good at being nice, but we’re not very good at asking the ‘tough’ questions. “ARE YOU OKAY??” “ARE YOU COPING??” “YOUR ANSWER DOES NOT HAVE TO BE A NOD AND A SMILE.”

Never forget, you are NOT alone in your struggles. It does not make you any less of a doctor. No matter how hopeless it may feel, it is NEVER hopeless. And there is always someone you can talk to.

My Rock Bottom was driving home at ten thirty at night after yet another long day and wondering to myself, should I keep pushing the speed limit because, maybe, just maybe, my wheels would slip and… …that would be that.

Three months later, here I sit, sharing the one experience I never imagined I could share.

There is always Hope.

There is always someone you can talk to.

And never, never forget, you are doing a good job. You are a doctor. Everyday you are helping people with what you do. Never, never forget that.

Okay?

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‘Discharged to Mortuary,’ Part 1: May you rest in peace

April 18th, 2011

The week I took home my brand new burgundy Littmann II stethoscope (sans engraving in the end), I joked with friends and family that the only thing I could tell you was whether or not you were still alive. Ha, ha, hahaha… Funny how those words echoed in my mind three years later as I stood alone over a patient whose life — spirit — had just left their body. Just me and a human being who was now quite possibly 21 grams lighter.

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Sometimes, showing up is the victory

April 3rd, 2011

Having returned from my fourth quarter elective just days before the start of work, I had barely re-synched my Circadian clock let alone given much thought to work life proper. Maybe that was part of my adjustment process — a sort of psychological denial. “That’s Future Anna’s problem,” I often thought to myself as my Clinical Handbook collected dust during my three months in West Africa. But as D-Day grew closer and closer, there was no more denying it.

Depending on the hospital, Orientation can span a few days to a week, mine being the latter. Getting back into the routine of an 8 to 5 day was harder than I thought it would be. (Yet nothing compared to the days to come on the ward!) On our first day of Orientation we stood in line outside the Security office to get our photos taken for our ID badges. It’s quite a curious sensation, looking down at your photo and your name — the essence of the familiar – but now with the oh-so unfamiliar preceding title, Dr. Those two letters felt so obtrusive, so loud, and pretty damn scary because with it came not just free meals but, for the first time in my life, Expectations and Responsibility.

I have to admit I kept glancing at my ID badge throughout the rest of the day. Not out of narcissism but more disbelief, almost as if to check it was still me they were referring to. Doing medicine is not just a job, one we leave at the door on our way out, but something that becomes a part of our identity. A new skin we put on for life. And what makes those first few weeks of transition that much stranger is getting used to this new skin.

The night before my first day I found myself more anxious than I ever thought I would be, on a deeper level than I ever expected. I think it was the sinking realisation that there was no turning back. Sure I was excited, and I had been all throughout Trainee Intern year. But in those final hours, as I lay in bed trying to imagine the day ahead, I was 99.9% nervous. This was it.

The first day itself wasn’t that bad. Sure you feel completely out of your depth, you don’t know how the system works (unless you’ve worked at the hospital before, which I hadn’t), and you haven’t yet bonded with the fax machine so those trust issues remain, but you get through it. You get through the day, you get home – exhausted – eat, shower, get into bed, and then a few hours later you get back up for day number 2. Then sooner or later you’re driving home from day number 5 when it suddenly dawns on you that you’ve made it through your first week as a doctor. It may not have felt very doctor-ly, you may not have jumped on any chests, but you showed up and did the job they expected you to do and (hopefully) no one complained.

For a handful of you, day number 5 will not be the end of your week. Like me, you may be rostered to work your very first weekend. Again, depending on your hospital ‘working the weekend’ will mean different things. For some it may mean either a Saturday or Sunday. At my hospital, it means 12-day stretches. And with that, you find yourself wondering how you will ever get through it.

But you do.

I wish I had something more helpful to say, some tips or tricks or a piece of pragmatic advice. But I don’t. All I can say is that you will get through it.

With time, you may even start to develop your own unexpected coping mechanisms. For me it was a morning coffee, a rainbow on my shoe or a flower in my hair and, for a couple of weeks, Justin Bieber’s ‘Baby’ pulsing through my iPod en route to the ward. (Admittedly, that quickly phased itself out.) These were but little reminders to myself that the ward is not the world, and the world is not the ward; that I was still a human being and not the discharge-summary-producing-medication-charting-IV-line-inserting-emotionless-heartless machine.

Day 12, standing outside the main hospital entrance I must have been quite the vision (and not in a good way). Waiting for my ride to the airport for grad weekend in Dunedin, I was exhausted with frazzled hair, dark circles under my eyes, shoulders slumped forward, and if I’m being completely honest, probably a little smelly. Too tired to be excited, all I wanted was to drive home in the other direction and collapse into bed. It goes without saying, grad weekend was truly special and I wouldn’t have missed it for anything. But flying back home Sunday night I found myself even more exhausted yet again, a new low.

In those first few months you will have many ‘new lows.’ There will be periods of time when you might have to give up on the running or the tennis; when you find yourself eating out most nights because you’re too tired to cook; when you don’t get to make any plans with friends or family, full stop. The advice you get throughout med school lingers in your mind – keep up the exercise; eat healthy; make plans and see friends, especially those outside of medicine; have a life beyond the hospital; set goals, try new things. And on that front, for me it felt like it was yet another thing I was failing at.

Pause. Deep breath in.

But two things to remember. First of all, ‘That too will pass.’ There will be early finishes where you can make it to the gym or go for that run; there will be some weeks where your team isn’t on take constantly; and there will be a rotation where every day is an almost guaranteed 4.30pm finish. And secondly, but more importantly, sometimes showing up for work is a victory unto itself.  You showed up, man. You did good. Don’t ever forget that.

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Accounts of a not-so-well being

March 30th, 2011

My friend from medical school and fellow intern is currently on holiday in the U.K. After driving her to the airport I sat with her in the Terminal as she filled out the Departure Card.

“What do I write under ‘Occupation’?” she looked at me and asked.

“Well, what’s your occupation?” I replied matter-of-factly.

“But I don’t want to write that.” She paused, considering her options. “I’m just going to leave it blank.”

“If you do that, they’ll just make you fill it out as you go through Immigration,” I said teasingly.

Further pause. “Then I’ll write ‘Student’.”

I pointed to the fine print underneath the signature panel, which committed the signatory to a truthful declaration.

“Ugh!” she bemoaned, frustrated but acquiescent. “Fine, but there better be other doctors on the plane, and at least one consultant.”

During med school, and especially in our final year, we try to imagine what it will be like, when the name on our hospital ID badge suddenly has the gravitas of those two magic letters, ‘Dr’. I can’t remember what I was expecting but speaking as a now three-month-old doctor all I can tell you is that I completely underestimated how hard it would be and completely overestimated my personal abilities. A huge error of judgement, to say the least.

As a student our greatest fear is that we don’t know enough. Those esoteric classifications, eponymous syndromes, and expansive lists of differentials memorised for exams have long been forgotten. But the truth is, that should be the least of your worries, because if med school has taught us anything it’s the medicine. What makes this transition an almost un-human experience is all the stuff they don’t talk about. How does a mere mortal deal with physical, emotional, and psychological EXHAUSTION? How does a [insert personality type here] master the subtle art of successfully working with a plethora of other professionals, each with a personality of their own? How does a person respond to the angry, complaining, noncompliant, dying patient, and their family? But more importantly, how does one human being with just two hands and one brain do all three simultaneously… at 4.30pm… on Day 10 of a 12-day stretch… all the while second-guessing even your smallest clinical decision … constantly wondering, am I unknowingly making that one mistake worthy of NZ Herald’s front-page? ‘Exhausted Junior Doctor Makes Fatal Error.’

I in no way proclaim to have the answers. I am but one human being with two hands and one brain trying to keep my head above water. And in all honesty, I have found myself floundering – truly floundering – for the first time in my life. Normally a proponent of jumping into the deep end, I romanced one of the biggest hospitals in the country, selected one of the busiest runs to start on, to serve one of the most difficult patient groups. That is the bed I made, the bed on which I have had to lie these three months passed.

A few of the issues I faced may have been specific to my situation, my personality, or my gender. But at the end of the day ask any intern how they’ve found their first run and you’ll find we have all struggled. It does start to get easier – slowly, painfully – with time and with experience, but there will come moments where it feels impossible to catch your breath. With this in mind I want to share with you some of my ‘rock bottom’ moments. A raw and unfiltered account from a pragmatic optimist who found herself one day a student, the next day a doctor, and then in the months that followed, a not-so-well being.

- A. A. Choi

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