“Senior” House Officer: Doc, where’s my steth?

Firmly in the category of Things No One Asked For (wedged between merchandising coffee mugs and your annual pelvic exam) this one is all about how I spent my Senior House Officer year. If anyone is still reading this to get some idea about medical life in Jamaica, you’re in luck. Everyone else, bear with me.

For my SHO year (the second year of relative supervision, coming after internship and before postgraduate study), I spent four months at the hospital in Internal Medicine and eight months in primary care bouncing around the clinics of St. James and Hanover. I had wanted an even six month split but the powers-that-be changed the schedule from two six-month rotations to three rotations of four months each, likely as an incentive for doctors to spend at least some of their time in primary care (which is woefully understaffed).

While I enjoy solving the diagnostic mysteries of Internal Medicine and relish the mental challenges of our limited resource setting, I did not particularly like my time at the hospital. One of the reasons is the aforementioned limited resources, which made it exponentially harder to get the job done (the job being getting the patient better and out of the hospital) but another more important reason was the unhealthy and sometimes toxic working atmosphere.

Doctors in hospitals across the world have to battle against so many barriers to effective patient care. Sure there are administrative and technical hurdles, but one of the most damaging and pervasive problems doctors face is other doctors. We can be unkind and unsympathetic toward our colleagues, we can be harsh and critical where kindness and compassion are needed. We can be overly competitive, deliberately misleading, and frankly aggressive. Specialties often argue instead of cooperating, departmental heads are sometimes overbearing and the support staff is at times less than supportive.

I frequently left work feeling like I spent the last 8-36 hours running a hamster wheel, exhausting myself and getting nowhere. For all my efforts I was yet to see any noticeable improvement in the quality of care being offered, and in fact quality of care was on the decline as Cornwall Regional was on the brink of a crisis by the time I had moved to my next rotation.

Unlike its older brother, primary care has no pretensions about the level of care it is able to offer. Clinics don’t promise CAT scans and then tell you the machine isn’t working; or promise urgent lab results that take hours to be processed. Primary care understands that its role is to prevent and screen, to catch the life-threatening emergencies before they become life-threatening. And that pace is so far suiting me just fine.

Hanover is the smallest parish in Jamaica, splitting its geography between enchanting sea vistas and rolling hills of green green bamboo. I spent my four months here really sharpening my clinical skills and patient interactions. I honed my management of chronic illnesses and developed some much-needed confidence (from all the time spent in clinic by myself because there weren’t enough senior doctors available). Hanover’s narrow, winding roads are where I learnt to drive and the country clinics reinforced all the stories I hear about the generosity of rural folk. I was sad to leave it behind.

(Spoiler alert: I’m stationed back in Hanover for the foreseeable future)

The camaraderie and team spirit were like a breath of fresh air after Cornwall’s sometimes hostile overtones. I felt more comfortable offering care at a less urgent pace (even though we had our fair share of emergencies!) and I appreciated the opportunity to effect behaviour change before it got to the stage where tertiary or secondary care was needed.

Despite challenges with patients’ educational level and access to care I still believe that primary care is where our efforts need to be concentrated if we are ever going to make our country truly healthy.

But enough about me. SHO year is all about testing the waters and seeing where your passion lies. It’s about picking up skills you think are important and spending time with physicians or surgeons or anesthetists who you think can teach you a thing or two. Internship is merely meant to be survived; SHO is where you thrive. Attack the smorgasbord of hospital specialties like an all-you-can-eat buffet, or settle down to dine at one specialty for the whole time – it’s up to you. Just remember that along the way you’re molding yourself into the medical officer or resident who will be the ‘senior’ by the start of the next year.

What kind of senior do you want to be?

Should you go to Med School? Probably not.

Medicine has long enjoyed its reputation as a distinguished and well-respected profession with an assortment of perks. Not just in Jamaica but worldwide, doctors rank up there with lawyers and politicians in the hierarchy of  ‘jobs you want your kids to have’. Children with even a mediocre aptitude for science get pushed into medicine and often for the wrong reasons. If you want to be a doctor because you “like helping people” or just so you can put that “Dr” in front of your name you probably shouldn’t go to medical school.

If you like helping people that’s awesome, but you have to be realistic about what exactly you’re working toward and what that work involves. (If you just want the fancy title, get out now). I’m not trying to discourage anyone from becoming a doctor but I do think it needs to be said that being a doctor isn’t for everyone. Similarly, being a garbage collector or plumber isn’t for everyone. And yet someone has to do it. You can appreciate this comparison once you understand that the way we ascribe meaning to jobs is totally arbitrary and ultimately pointless.

People who create immense joy and inspiration like musicians or writers are not revered or compensated equivalent to the value of the work they produce. Conversely our government leaders who exist to serve the tax-payers who elected them are revered and compensated entirely out of proportion to the work they don’t produce.

The bottom line is this: If you could be guaranteed the same amount of wealth and respect by working as a grass cutter (or any other underpaid job), would you still want to be a doctor?

If you said yes, be prepared for a lifetime of hard fucking work. Getting accepted to medical school is only the first hurdle, and it’s a pretty big one. You need the right grades and a decent collection of co-curricular activities. In today’s society it helps if you know the right people. The sheer number of applicants to medical schools annually is staggering; competition is fierce and it will be like this for most of your career.

Aside: If you don’t get into medical school it isn’t the end of the world. If after reading this article and doing your research you decide that you 110% want to do medicine there are ways and means. And you’re young, you have so much time. If after the soul-searching and the research you decide it isn’t for you then congratulations! Go do something that makes your heart sing.

Let’s say you get accepted to medical school here at the University of the West Indies. If your parents can’t afford to, you now have to figure out how to finance all five years of your education. A part-time job is out of the question because you won’t have the time, scholarships are hard to come by and student loans are expensive to repay. Where do you turn then?

Let’s say you decide to take out a student loan. Now you have to hit the ground running with your studies. Medical school is essentially a brain dump of information, most of which has to be memorized until you can understand it enough to apply it. There is constant competition among your peers in tutorials and exams and a stifling atmosphere of one-upmanship. The pressure to continuously outperform your colleagues rarely lets up. Starting here and continuing for a good half of your career, sleep will become a hypothetical concept.

Once you graduate, you’re staring down the barrel of what will probably be the worst year of your life. Internship is a grueling marathon of stamina and skill with the added weight of being responsible for people’s lives. And halfway through the year, if you took out loans, the Student Loan Bureau will come knocking.

If you decide to pursue postgraduate studies, you’re looking at another 3-5 years of school, loans and now trying to balance your family life (probably) with your career and education. If you don’t pursue postgraduate studies, your marketability plummets and your pay grade stagnates. Either way you will probably go prematurely gray from the stress of it all.

If you’re still not re-considering, you’re likely thinking one of the following thoughts:

But doctors are rich!

Unless they inherited wealth (which admittedly, a good many doctors do) doctors aren’t rich. For an average Joe from a lower to middle income family, it takes several hours of overtime to maintain the lifestyle the public usually associates with doctors, especially in the early years of a career. In the grand scheme of income rates, Jamaican doctors get paid very poorly compared to our international counterparts (even South African doctors get more money than we do). But there a lot of different factors influencing how much money you make, most importantly post-graduate study.

But doctors are well-liked/respected!

This is true to some extent. Certainly doctors have special privileges: people smile at you more (people smile at puppies a lot too), you can stand as a character reference (so can ministers of religion) and banks tend to want to lend you money (it’s a trap, Jim). But like Uncle Ben said, with great power comes great responsibility. And if you slip up even once it’s a long way down.

But doctors are _______!

It doesn’t make sense to generalize. The experience of the doctors you have so far been in contact with will not be your experience. The field of medicine is constantly changing and rapidly evolving. It isn’t now what it was fifty or even ten years ago. Technology makes things easier and harder, popularity and accessibility make competition a hundred times fiercer, and regulatory bodies have turned medicine into a business, always looking at the bottom line.

The volatile landscape of the medical profession demands a special kind of adventurous spirit who does their research beforehand. Map your territory. Talk to a medical student, talk to a young doctor, talk to an older doctor, shadow them at work, flip through a medical journal, visit a hospital. Get a feel for the shoes you’ll be walking in.

And after you’ve done all that, talk to yourself. If you have a keen interest in helping people, if you love challenges and relish hard work (and care very little for sleep), if you’re naturally competitive and have a good head for business with a passable understanding of the human body then medicine might be the career for you. Otherwise, set your sights elsewhere. Preferably something in line with your natural inclinations.

Might I suggest Banking and Finance?

Dear UWI: Please Wear Your Size

Once upon a time medical school class sizes numbered about 40 people. The student : consultant and student : patient ratios were low. Everyone had an equal opportunity to see and touch and hear things. Future doctors had to know all the things, had to write essays, had only a handful of textbooks and a ward full of patients. All was right in the world.

The good old days.

Then came the surge in tertiary education accessibility and this strange idea that everyone who was bright had to do science i.e. medicine. What followed was a welcome blossoming of the medical field. Now we had extra doctors to fill in the gaps previously patched up by family nurse practitioners and old doctors long past retirement. All was even better with the world.

But the numbers kept climbing. What started as a welcome trickle soon became an unstoppable torrent and the volume of graduates was starting to spill over the buckets we had to catch them. It’s been going on for a while, but in the last three years it’s been getting a lot more noticeable.

It’s not just the numbers that are the problem, either. Historically, UWI doctors have a reputation for being unparalleled clinicians because of the overwhelming amount of exposure we’re supposed to get on the wards. Our consultants tell us stories about being in final year and getting a stipend for acting as interns. They’re full of back in the day type stories but to us they’re just that: stories.

Our reality is lecturers who are a hundred miles away, histology specimens on LCD screens and anatomy labs where we balance precariously on high stools praying we don’t fall face-first into the formalin.  Our reality is two junior students plus one senior student assigned to one patient in addition to the team that’s actually taking care of them.

Our reality is the super clever students answering all the questions meanwhile those of us who are not so clever mill around at the back of a ward round with 20-odd people without quite following the discussion. Our reality is a million different textbooks and the indefatigable expanse of the internet and consultants who constantly contradict themselves. Sometimes medical school is also a negotiation of egos.

Everyone knows one of these people.

Older consultants complain that the quality of the UWI medical student is declining. It’s true. When female med students show up in rompers to the hospital, or when a med student back-chats a consultant in exams, or when they can quote Bailey and Love’s back at you but don’t know the first thing about their patient’s procedures. These all represent a shift from previous standards, a downward shift.

But between the student and the consultant lies the administration. And the administration seems somehow disconnected from the goings on of the very people they administer to. Class sizes are uncomfortably large and the university responds by building basic sciences buildings big enough to fit everyone in. But the clinical spaces are the same size as they were five, ten, fifteen years ago.

There are not enough hospitals, not enough consultants who volunteer to be associate lecturers (I have to say volunteer because one common complaint about UWI is that they never pay anyone), and most importantly not enough patients.

We overwhelm everyone when we step onto the wards, every single time. There are only so many variations on ‘There are so many of you!’ that one can hear before one gets fed up.

‘You won’t all fit’,

‘You can’t all go at once’,

‘Some of you have to stay outside’,

‘Decide which one of you gets to do it’.

Please. It’s not our fault our class is this big. None of us have dropped out yet.

Yet despite the glut of doctors on the market and the increasing difficulties faced by medical students on the wards and in clinic the UWI doesn’t think to cut back on medical school entrants. They’re rolling out the red carpet for everyone. Everyone who can afford it, that is.

Grades aren’t a good enough criteria any more: everyone has Grade Is and IIs in CAPE, and co-curricular activities, and higher than 3.3 GPAs so now it’s the ability to actually afford medical school that separates the wheat from the chaff.

Actually, one does.

And once you can afford to get in, the long ago shift from essay questions to MCQs makes it infinitely easier to keep passing exams and make it to final year, MBBS and graduation. The standard of medical student isn’t the only standard that’s dropping here.

I wish our university would realize that trying to fit 500 medical students into a system with nowhere near that kind of capacity is like trying to pour 160lbs into size 2 jeans. The non-stretch kind. There is no stretch in this cotton, UWI.

We are the adipose pushing at your waistband, and one day the seams will burst.