Visions (but not like, the high kind)

Lately I’ve been feeling really stressed out at work. Proper stress: headaches, stomach aches, feeling like I was about to explode from internal pressure. I was freaking out about my work responsibilities which seemed to loom ever larger in my paranoid imagination, but in reality were only so intimidating because I was setting the bar so very high for myself.

I started listening to this podcast a few months ago. And while it’s a kick-ass repository of career advice and entertaining conversations on how to be awesome at your job, it was also setting me up for failure. Every new technique I learnt, I wanted to start doing immediately. I judged my own growth against concepts and ideas from more experienced professionals and found myself painfully lacking. I threw myself into a fit, trying to ‘catch up’ and ‘do it all’. My control freak tendencies came out full force.

And week after week, my job resisted all attempts at micromanaging. Shockingly, people are impossible to control. I know this is breaking news to you guys, so maybe take a second to get used to this epiphany. Patients do whatever the hell they want, responsibilities and priorities shift all the time, colleagues do not share your work ethic, etc etc.

Mercifully, the culmination of all this stress was a breakthrough and not a breakdown. Driving home on the verge of tears for the fifth Monday in a row I let my thoughts swirl around the car interior like angry wasps. Then among the wasps, wisps of remembered conversations and podcasts snippets coalesced to remind me of a word I had forgotten in my desperate scramble to control.

Vision.

I didn’t have any. Or I had too much. I didn’t know, because in the middle of all this over-thinking and I had never actually stopped to think about what I wanted to make happen. I was furiously building a boat on dry land without ever having dreamed of the sea.

So I started dreaming, and I started writing things down. I wrote quickly, more concerned with getting the ideas out of my head before they exploded my head. I edited after, because I have standards.

And incredibly I felt lighter. The stress had shifted from an angry hornet’s nest to a more manageable ball of barbed wire. I knew what I was aiming for now, what the end result should look like, and I had something I could show to other people and ask for help so I’d feel less alone. It was incredible.

In his seminal work, Stephen Covey talks about how important it is for a leader to have vision. He makes the analogy of a group of people in a forest working to clear a path, with managers directing the machete-wielders to chop down the right set of trees. But the leader is the one who climbs up, looks around and yells, ‘Wrong forest!’

And honestly, I understood that when I was reading it. Yes, obviously vision is important. 2+2=4. Duh. But I didn’t really get it until I had finished mapping my own visions and realized, with great humility, that this was the most important part of the job all along.

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Reflections and Re-purposing

It’s officially a year since I left hospital medicine and ventured into the clinics and primary care. Like Lot’s daughters I never looked back to watch the world I once lived in burn, almost literally. I’ve wholeheartedly embraced this strange new territory and I’m coming to think of it as my home.

There’s a lot going on with primary care in Jamaica. One news story just a few months ago reported on the high level of dissatisfaction patients have with the way service is delivered. Primary care is plagued by low resources, for a number of unfortunate reasons. And primary care as a system is badly fragmented. There are many gaps in this new world.

When I walked sprinted out of secondary care I did it with a vow in my heart: I would try as hard as I could to prevent the untimely deaths and strokes and heart attacks that were caused by manageable chronic diseases. I was eager, I was willing and I was hopelessly naive. Stepping into clinic was like being splashed in the face with cold water; determination would only take me so far, about as far as the burnt out bridges of patient behaviour and system capacity. My sprint slowed when I realized this could not be the only direction I expended my efforts in. I needed to study the system to understand how to improve it.

So I began to learn, as much as I could and as often as anyone would let me. I didn’t just start to learn about holistic patient care, I started reaching for every training session that passed my way. The closer I got to the source, meaning the Ministry of Health, the more I was able to identify the gaps between protocol and reality. We play a hard-core game of Chinese telephone with our standards that usually ends with the front-line health care worker simply doing the best they can with what they have. This system was a mystery I was determined to unravel, and that curiosity illuminated an unexpected career goal.

I love organization. I love rules and protocols and standards and guidelines. It tickles my fancy to improve system efficiency, to find innovative and easier methods to meet goals and targets. And as it turns out, all those things that people in high school called me weird for liking are actually super important to the world of work. Those skills and interests can translate into actual jobs, with the right qualifications to back them up.

So it seems that after all these years of worry about a loveless career I am now falling, stumbling, eagerly crawling toward a purpose that resonates with my own ‘weird’ frequency. Hurrah.

Nepotism, hamster wheels and career-sized roadblocks

This career we call medicine has so many taboos, so many topics everyone seems to avoid talking about.

Like how much we’re really making. Or how to move up the career ladder. Like private practice, emphasis on the private. Or pension schemes and permanent appointments. Like opportunities for postgraduate study. Or the nepotism this country wears like a second skin.

When we get together as a group we’re always talking about wacky patients, the dire lack of resources, horrible bosses or survival stories. Advice is limited to clinical discussions, and a lot of the mid-career medical professionals seem too busy trying to further their careers to steer a junior down the right path.

In the ‘glory days’, medicine was an apprenticeship. Younger doctors worked closely with their older counterparts, learning everything they had to teach about the human condition (medical and social). At the same time, medicine was a lot more paternalistic with physicians adopting an almost godlike role in society. So some change is for the better. But now most doctors play their cards close to the vest, for some reason reluctant to share their hard-earned wisdom.

It’s true that the world of medicine is significantly more competitive now than it was fifty years ago. You can’t throw a stone in Montego Bay without hitting a doctor’s office (some charging a measly $1000 (USD$7) for visits). While medical schools continue to graduate hundreds of hungry indebted interns every year. In Jamaica where everybody haffi eat a food the stiff competition breeds contempt and secrecy, jealousy and sabotage.

But to what end?

The crab in a barrel mentality of stepping on a brother just so you can move up a scant centimetre on the socioeconomic scale is not going to work in the long run. Resources and opportunities shouldn’t be so scarce that we have to fight to the death for them. Information ought to be shared equally, not bottled up and parceled out to a privileged few. Younger doctors should not be forced to reinvent the wheel when there is a wealth of experience available for tapping in to.

We’re told, work hard and you will be rewarded. We’re told, if you want good yu nose haffi run. We’re told, I went through the struggle now it’s your turn. No support, very little encouragement, and everyone more tight-lipped about career advice than a gang of Sicilian mobsters.

Maybe I’m too young, too idealistic, too millennial to simply fit right in as another cog in the nepotistic hamster wheel of capitalism that Jamaica seems stuck on. Either I’ll find a way to make the system work for me, or get flung violently off the ride like the broken ill-fitting piece of machinery I really am.

Only time will tell.

What is a CRH Internship like?

So here we are, one year out of medical school. Internship is behind us and we’re venturing out into the world of fully registered medical practice. And the question one everyone’s (no-one’s) mind is, what is internship at CRH like?

Internship anywhere in Jamaica and the Caribbean is rough. The high patient load and typically low resources keep our clinical practice particularly inventive, and adhering to evidence based medicine is a lot like playing whack-a-mole (just when you think you’ve hit the nail on the head, it’s disappeared and you have to try again).

I chose CRH for my internship for a number of reasons. Montego Bay is my hometown. Because it’s a Type A hospital we see more complicated cases and therefore get more clinical experience. Compared to the other two Type A hospitals, the patient load is a balance between overwhelming and nonexistent and the staff are (for the most part) approachable.

Surgery, Internal Medicine, Pediatric Medicine and Obstetrics & Gynaecology share the same basic traits no matter where in the world you practice. What I have found different is the slant of intern duties. In my opinion, a CRH internship gives you primarily clerical experience. Any additional medical experience is dependent on the interest and enthusiasm of the individual intern.

Broadly speaking, the intern’s job is to see or SOAP inpatients every morning, round with the consultant, carry out requested procedures and tests, and follow up the results of these tests and act on them. Variations of this theme can have the intern seeing or clerking new patients in the Emergency Department, making interdepartmental referrals, organizing procedures off the compound, administering medication etc etc.

At the end of the day the intern’s is tasked with making sure the patient gets whatever they need to get better and get out of the hospital.

A lot of your time is going to be spent writing request forms, writing referral forms, writing notes in the docket and writing orders for medication. Your practical procedures will primarily involve phlebotomy and placing intravenous accesses. There will be times when you don’t feel like a contributing member of the team and there will be times when you’re the one leading ward rounds. There will be plenty of opportunities for learning, and in the same breath you will feel stifled by your supervisor when they only want you to be a scribe and a gopher. Brush these moments off and look for teaching moments. They’re not always obvious, but you can learn something from everyone.

Surgery

On the Surgery rotation, interns spend six weeks in General Surgery and six weeks in a surgical specialty such as Urology, Orthopaedics or Paediatric Surgery (Neurosurgery didn’t take any interns at the time). There’s a lot of hands on experience to be had here, participating in major and minor operations like laparotomies, appendectomies and the ever-frequent digital amputation. It’s impossible to leave this rotation without knowing how to suture and the basics of pre-op and post-op care, especially since the intern is the one leading the ward rounds, the one with primary management of inpatients.

Paediatrics

Paediatric Medicine divides your time in two six week blocks of the paediatric ward and the special care nursery. Here you learn attention to detail, the importance of acting on the results of investigations and how to handle stress. While on paediatrics you pick up skills in lumbar puncture and intravenous access placement, medication administration and infection control. Interns on Paediatrics are responsible for  administering all IV medication, which is something unique to CRH. If this doesn’t sound daunting, it should. The ward capacity is 20 patients (each. For the ward and the SCN), who require medication up to four times per day.

Medicine

Internal Medicine is a straight three month block with no sub-specialization (small chance of getting some Nephrology exposure). Patient load is high, resources are low and most of your patients are frequent visitors to the ED. It can get frustrating, especially if you like ‘saving people’ because the majority of patients are repeatedly sick because they are non-compliant. There are a lot of social and economic reasons behind this non-compliance but tertiary facilities are the ones feeling the brunt of that primary care failure. This is where you hone the twin skills of BLS/ACLS and breaking bad news. The practice of Internal Medicine is roughly the same across the board, with variations in level of academic exposure and access to resources (CRH falls low on both spectra).

Obs/Gynae

Finally, Obstetrics and Gynaecology is the Other surgical rotation, where instead of gunshot wounds and pus filled abdomens you get happy bouncing babies and failed abortions. The scope of your exposure ranges from suturing multigravid vaginal lacerations to contacting the Centre for Investigation of Sexual Offences and Child Abuse (CISOCA) for your 13 year old patient with pelvic inflammatory disease. OB/GYNs balance surgery and medicine remarkably well, with a smattering of paediatrics (neonatal jaundice has to be diagnosed by the OB/GYN intern before referring to Paeds) and the general atmosphere of the department is one of bonhomie. Interns on O&G  don’t have very active roles in patient management (most of the decisions are made by the consultant, with the intern carrying out the orders) and the consultants round daily so you’re never really on your own (pros and cons, here).

Conclusion

CRH definitely has its ups  – interns have the option for on-compound housing, for instance – and its downs – necessary machines get broken, a lot. And at the end of the day the decision about where to do internship is multi-factorial. I wish I could offer a comparison among internship sites in Jamaica or even the wider Caribbean but alas. I’m not so lucky enough to have enough friends in high and low places.

I will say this: no matter where in the island or Caribbean you do internship, almost everyone will be prepping for USMLEs or some other foreign licensing exam. Internship may feel like the worst year of your life (and in some ways, it is) but it’s just a stepping stone to postgraduate qualifications and the start of your actual medical career.

Just because you can doesn’t mean you should. I’m looking at you, serial killers.

By now, no one reading this should think I’m in medical school because I have a burning desire to help people and/or change the world. I mean, yes, I have a desire to do both, but frankly being a doctor is probably the last route I’d choose to achieve that. For several reasons. None of which I’ll be going into (now, at least).

I am here, more or less, because I can be. I am still in medical school because they haven’t kicked me out yet. Because I haven’t failed anything (knock on wood, KNOCK ON WOOD). Because Kharif has managed to talk me out of my two very serious, very impractical plans to drop out of medical school and be a happy bohemian. Because it’s impossible to do that in Jamaica (the happy part; it’s ridiculously easy to be bohemian here).

That’s the way things are done in this country. If you’re smart and good at science – do medicine. If you’re smart and good at words – do law. People will always tell children that they talk so much they should be a lawyer, like a back-handed complimentary self-fulfilling prophecy. If you’re not brilliant at words or science, you pretty much get to do whatever. In the realm of business. Or teaching. That’s if you make it to university, of course.

(No offense, businesspeople and teachers. I have the utmost respect for you. As long as you’re doing your job right).

I’m not saying I got pigeon-holed into a career path. I’ve got no right to demand the same commiseration as people whose parents pushed them into something they’re going to regret for the rest of their lives (unless you count that time my mother made me stop dancing for two years in high school. But we’re not counting that). I went into medicine fully cognizant of the fact that not following your passions will make you miserable, but I was all about the hard life. And I also figured that since I had the aptitude, didn’t that mean I was obligated to serve my country in a way that not many people could?

I have since come to realize that that was utter BS. The great thing about passions (and similarly, talent) is that they’re wildly different for a reason. Every passion or talent can be harnessed to contribute meaningfully to society. Except serial killing. Unless maybe you only killed other serial killers? THERE CAN ONLY BE ONE.

What I mean is, in an ideal society everyone would be doing what they loved best and society would thrive because of it. You wouldn’t need to bribe people with fringe benefits or yell at them with sticks (ballpoint pens? Clearly I have no idea how an office is run) to get them to do work. They’d do it because they loved it, every one: doctors, artists, lawyers, businessmen, garbage collectors, butchers, serial killers. (I’m kidding about the serial killers).

In an ideal world, passions wouldn’t have to get sacrificed so you can pay the bills. Or discarded because you couldn’t get in to the programme or job because it was full of people who had to give up on their own passions to pursue yours because it was more lucrative. (Protip: medicine is NOT lucrative).

And now I’m left wondering if I robbed someone of the chance to pursue their passion because I felt obligated to pursue medicine. I’m sorry nameless, faceless genuine lover of medicine, who probably got into med school the following year anyway. Because that’s another good thing about passions: where there’s a will there’s a way*. And med school is a whore for tuition-paying suckers. I mean students.

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* – what I mean by this trite cliche is: when you want something badly enough, and you are willing to go the extra mile to achieve it (I’m talking about intangible things here, not like a PS4 or Galaxy 3) the universe is propelled into granting you that desire. At least, that’s what I like to believe.

I’m at that age?

I have a confession to make: I spend an inordinate amount of my time on WordPress reading Mommy Blogs.

Something about these women’s stories of impending newborns, irate toddlers and cute kid moments just tugs at my heart strings and keeps me coming back for more. Is my biological alarm clock going off? Can I tell it to sleep for a couple more years?

I was chatting with a friend last night about how we kids in medical school are still waiting for our lives to start. I’ve talked about this issue before – dealing with friends who are now married, have kids, have jobs. But frankly it only gets worse the closer we get to our graduation date. Spending five years in university is an anomaly compared to everyone else. The girls now in first year on MSH are the same girls I will be graduating with in three years time. The cohort I entered university with is graduating next year. The math is all wrong.

Maybe that’s what my ovaries are trying to tell me by turning up the oestrogen and inducing this hunger for maternal information, secondhand or otherwise. Am I at the age when all I should be thinking about is starting a family? Curse you, my feminine body parts!

I have joined the ranks of (modern) women who put careers over kids, and financial independence over families. I’m not a fanatic feminist (okay, I’ll quit with the alliteration) but I recognize and appreciate the importance of having a good amount of stability in my life before I go complicating it with children. And children are complications, from the moment of their conception til the moment you move on to the afterlife. Cute, cocky, charming, frustrating complications.

So for now I’ll sate my totally irrational (but psychologically valid) instinct for nesting with stories of actual mamas dealing with their awesome, scary children.

Let the Mommy Blogs continue!

Mommy Blogs I read with astonishing regularity: 

Welcome to the Motherhood

The Bloggess (she counts. Sometimes. The Bloggess counts all the time).

Recent Mommy Blog from Freshly Pressed:

The Ramblings of a Pregnant Twenty-Something

This Mommy Blog fixation probably started with the friends I had on Livejournal, because all of them had kids and would tell stories about them in between the stories they shared about Harry Potter. So I blame Harry Potter.

For us, 30 is the new 20

And every tick of my tock, echoes like an angsty gunshot

A few months ago I read a Medscape article titled ‘Is Your Social Clock Ticking?’. I didn’t even know I had a social clock until that article. Now it feels like mine is counting down in seconds like bomb blasts.

I have never been a social person. Not introverted (not even close), just not excessively friendly. I don’t have Facebook or Twitter on an IV drip like most folks, and I really, really relish my alone time. But that article forced me to stop and look around at my peers. And what I saw gave me a jolt. People I was in class with in high school are married. They’re having kids. They have jobs. They’re married, for heaven’s sake. For them, the decade of their 20’s is all about establishing themselves as adults. And I know I’m talking about the segment that passed up or got passed over by tertiary education, but that’s still a good chunk of them. Enough to have me feeling (reluctantly) that some part of life is passing me by.

Because my 20’s are all about cobbling together a career, not starting a family. They are all about the hard work and not the pay off. The pay off will come much later, when I’m old enough to enjoy it (hopefully). Five or ten years from now when I’ve established my dreams *touch wood* and scratched up enough sanity to pass for an adult, I will be glad that I laid this foundation. So no, I don’t feel like I’m behind in life because I see people around me planting roots. These tedious and seldom-rewarding years are my roots, and I think they’re well worth it.

Pax.

Which side of the coin are you on? Do you feel like you’re in the running with your peer group or behind the game?