medicine

Why Hanover

Robyn, , , , , 5 Comments

From time to time I get quizzical looks when I tell people that I work in primary care (aka clinic) in Hanover, one of Jamaica’s most rural parishes. The eyebrows climb even higher when I further explain that no, I don’t have a private office somewhere.

Fellow doctors wonder how I survive on the salary (and compared to my hospital colleagues it is meagre). Patients who connect with me are disappointed that I only work in hot, overcrowded government facilities and not some low-traffic office with an air-conditioned waiting room. Would-be mentors are perhaps bemused by my preference for this rural space that offers little in the way of career advancement.

But I continue to choose Hanover year after year, even though my feet itch with wanderlust and three years is the longest time I’ve stayed in one place since high school.

But why?

Well, the parish is beautiful. Lucea overlooks a picturesque bay of rolling blue sea. Cascade overlooks lush green hills of swaying bamboo. For almost the entire length of the highway that passes through Hanover the sea is a few scant feet away from the road, replete with stunning sunsets and the cool calm breeze of true island living. But that isn’t it.

I stay in Hanover because I believe there is so much good I can do here.

Whether it’s running the parish’s first treatment clinic for persons living with HIV, or saying yes to every single patient that turns up at clinic in the hills no matter how full we already are, or spending the extra time to listen to an old man reminisce about his favourite son – there is so much good I have done, and so much that I can still do.

Clinics have a bad rap among patients. Somehow people developed the idea that hospital doctors are better (this is laughable because Hanover is so tiny that the same clinic doctors often also work at the hospital) and that clinics are not worth their time. But in the time that I’ve been working in Hanover (did I mention it’s been three years?) I’ve been so lucky to work alongside doctors and nurses who care passionately about the overall well-being of their patients, not only about their blood pressure or HbA1c.

The magic of primary care is really how one doctor or one nurse or one community health aide can make a dramatic difference in the outcome of a person’s health. The beauty and the privilege of my job is watching people not just improve their condition, but thrive with care and support.

The fulfillment that I get from my daily work reminds me why people look at medicine as a calling and not just a job. And while I won’t always work at the level of individual patient care, the purpose of my duties will always remain the same: to bring quality healthcare to the people who truly need it. They say you never forget your first love; and wherever I work in the world whether elsewhere in Jamaica or further abroad it is and always will be Hanover that has my heart.

on Internship

Robyn, , , , , , 2 Comments

Please enjoy this post I wrote 2 years ago while struggling to survive my intern year. The level of optimism is truly remarkable considering I was on my Paediatric rotation at the time.

The shift from medical school to internship is the shift from dipping one’s toes in the swimming pool to diving in the deep end. When you’re a medical student, duty ends at 10pm. If you can’t get an intravenous access, you call the intern. 12 o’clock is always lunchtime.

Suddenly, it’s July 1 and the minutes don’t roll over. Free paper has been burnt. You have passed the dreaded MBBS and received, in return for your labours, more hard work. Harder work, in fact. Your duties extend for 24 and 48 and 56 hours. Sleep becomes a concept. Lunchtime, a luxury. You become the person the medical student calls when they’ve destroyed all the veins in their quest for an IV access.

Why am I here again?

If you haven’t asked yourself that question at least once in the last six months, consider yourself lucky. You might actually want to try your hand at the Lotto.

If there was a buzzword for internship, disillusionment would be it. When asked what lessons have been gleaned from the “Internship Experience”, one intern from a hospital which shall remain nameless (we’ll call it the Really Tall One) responded with an outburst,

“Old doctors want our experience to be as frustrating as theirs to ‘build character’.”

You know it’s time for a paradigm shift when you point out workplace inadequacies and your boss responds with,

“You merely adopted high patient loads and low resources. I was born in it, molded by it. I didn’t have the luxury of readily available investigations until I was already a SR and by then it was an insult to my clinical acumen.”

It’s admirable to want your interns to be the best they can be but there are practices in medicine that in any other profession would spark the ire of an entire HR department. But I digress. This isn’t meant to be a call to arms.

Sometimes the answer to that ever-present question is positive. Real life patient care (as opposed to the dabbling that’s done in medical school) can be and has been rewarding and invigorating. The General Surgery rotation is particularly satisfying in this regard: patients enter the hospital bleeding, broken, dying and with the flick of a scalpel, the swish of a stitch (and some strong pain meds) they survive to maim themselves (or someone else) another day.

Lest this turn into a clichéd trope about the satisfaction of a job well done, I do have some misgivings about the surgical field. Once a patient expressed their profuse gratitude for having their infected digit amputated. You’re . . . welcome?

As uplifting as those moments are, they seem to be outweighed by the downsides of working in the public system. Like McGyver and Miss Lou, you has to tun yuh hand mek fashion. Whether it’s performing an entire sepsis screen (including lumbar puncture) on a neonate without assistance or manoeuvring a 250lb patient with bilateral skeletal traction off their stretcher and onto the CT machine, provided the CT machine is working. One disadvantage faced by every public hospital is inadequate funding, but necessity is the mother of invention. If you haven’t made an IV drip stand out of a curtain hook or a chest tube out of a Foley catheter, you haven’t really lived.

There is a certain satisfaction to seeing patients managed conscientiously despite low resource settings, but can medicine be equally reward and punishment? Ours is the lot of sleepless nights, thankless hours and the constant threat of occupational exposure (latent TB, anyone?). Is the smile of a mother when you tell her yes her baby can go home really worth the stress of q4hrly bilirubins?

As the most junior member of the medical team that stress of ‘getting it done’ rests squarely on the intern’s shoulders. It often feels like we’ve been left in the deep end of the pool to sink or swim, complete with Yoda-like figure declaring “do or do not, there is no try”. Coping mechanisms become currency as we try to stay afloat despite the setbacks. Periodic nervous breakdowns, the impenetrable veneer of cynicism and a strong tendency toward smoking and alcohol are only a few of the methods employed.

If you are stranded amidst the sea of disillusionment, clinging to the battered lifeboat of responsibility it helps, I think, to remember the reason you started out on this journey in the first place. Sankofa, my friends. It is okay to look back for that which you have forgotten. Whether it was the personal fulfilment you get from helping other people or the determination to be consultant someday, internship is decidedly BYOM. Bring Your Own Motivation.

At six months in we’ve already committed to this gestation period, for better or for worse. And when we are delivered in another six months, freshly registered and happy to be out of the frying pan of internship, we’ll look back from the fires of Senior House Officer year with the same clouded nostalgia as the consultants who believe that their internship experience was the only one worthwhile.

The more things change, the more they remain the same.

 

Reflections and Re-purposing

Robyn, , , , 4 Comments

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.

If It’s Monday this must be Lucea

Robyn, , , , , , 5 Comments

You might be wondering where I’ve been and what the hell I’ve been up to. I’ve been wondering that myself. My absence from this space hasn’t so much been a lack of things to talk about as feelings of uncertainty “am I allowed to talk about that?”. I will say that the confidential nature of my job isn’t exactly conducive to a personal blog, especially when most of the things I want to talk about are not always ‘fitting’ for ‘doctors’ to talk about, and I feel like my insignificant opinions carry more weight now. Self-censorship is hard to get over.

But I’m back. Because I feel as if I will burst if I do not write or yell something into the void. More catharsis than infomercial, this writing for me is therapeutic and I ask that you allow me the space to untangle my wrapped-up tied-up experiences.

My life these days is a delicate balance of work and school and relationships. Adulthood has a lot to do with balance, and I tend to measure my success as an adult by how well or how poorly I keep all these balls in the air. (Spoiler alert: I do not juggle well).

Moving up the career ladder from Senior House Officer to Medical Officer came with a new batch of responsibilities. This might seem logical to you, but I was wholly unprepared for later working hours, deadlines, reports and programme coordination; getting a new clinic off the ground, meetings with international stakeholders and the subsuming world of regional politics. It’s more than a mouthful, but it’s work that I’m excited about: making an impact on patients’ lives, experiencing infrastructural issues firsthand, being in a position to effect change, however minimal. I feel like I’m laying the foundations for the rest of my career so even though the building blocks might be heavy this groundwork will pave the way for something glorious. I hope.

In the same breath, I have been lucky enough to get a scholarship for an online Diploma programme taught by UWI St. Augustine. It’s a year long programme in the Clinical Management of HIV (an area I have grown very attached to) and I am in month two. I am discovering never before seen time management skills. They’re still new, like a foal on wobbly legs, but I haven’t missed a deadline yet which means progress. Yay, personal growth.

But like any of those ‘pick two’ triangles, one side just can’t seem to fit in with the rest.

6358199313103179052112482111_college-life-iim

My grandmother likes to complain about, among other things, the way I seem to be too busy to spend time with her. To my credit as a granddaughter I only screen about 10% of her calls and I see her almost weekly but I’ve noticed that parents and grandparents get more sentimental as they get older. I also missed my best friend’s birthday because I forgot to account for time zone differences and I haven’t seen my other close friend in months because of our crazy schedules (she’s a new mom and I work in a different parish). The point is that balance gets harder as you get older, and if like me you didn’t have much practice before it will take a lot of stretching to get it right.

I’m not including moving house and furnishing a new apartment, keeping my cat happy, maintaining a healthy relationship with my partner, trying not to kill the houseplants or my second and third jobs in the hospital and elsewhere because that’s another mouthful. It gets stressful and frustrating and I’m constantly questioning whether I’m making the right choices. Sometimes it’s hard to tell, especially with all the background noise of the rest of the country and the wider world. Violence, bullying and bigotry seem to be run of the mill these days but I still have to follow through on the paths I choose to tread.

Of course there are times when I drop the ball, when I miss the mark for perfect daughter/partner/colleague, times when I have to say no for my sanity instead of saying yes for a million other reasons and the negative self-talk threatens to drown me in tears. But I am learning that adulthood, at least for me, means walking on these wobbly legs until I’m strong enough to gallop in the direction of my dreams.

 

Dear Patients: Please Stop Asking Me for Sick Leave

Robyn, , , , 2 Comments

Dear Patients,

Please stop asking me to write you sick leave and then getting disgruntled when I say no. If I don’t think you’re sick enough to stay home then that is the medical opinion you have paid/waited in line for. If you don’t like it you can go and pay/wait in line somewhere else. Please stop asking us (doctors) to compromise our ethical standards (and potentially risk losing our license to practice) for your benefit. It’s considered fraud. I wouldn’t show up to your place of work asking you to break the rules; I only want you to extend the same courtesy to us.

Sincerely,

‘Doc’

P.S.

While we’re at it, please stop asking me to write your prescription in someone else’s name. It’s not just that your boyfriend clearly has no medical use for the vaginal inserts I’ve prescribed for you, it’s also insurance fraud. Thank you.

 

Doctors and Mental Health

Robyn, , , , , , , 6 Comments

The lives of medical professionals (at least the part of our lives that we choose to share with the public) are a lot like Instagram posts: lots of happy, successful moments to build the image of being competent and caring. But just like Instagram, real life is never as perfect as that carefully curated snapshot.

If you remember my last post about the things we don’t talk about, there was one really important topic I left off that list:  mental health. Just like physical health, our psychological well-being is integral to the way we function. But while we won’t hesitate to get ourselves checked at the first sign of illness, we balk at the idea of talking about our feelings or worse, spending time in therapy.

Sometimes we don’t talk about it because we feel our patients need to believe that their doctor is operating at peak performance. Discussing our mental health issues openly, or even acknowledging them can have a detrimental impact on the physician-patient relationship. Patients tend to think of doctors as superhuman, somehow immune to the struggles that plague the average person. In reality, doctors have the same problems as everyone else. But we don’t like to be reminded of that. We buy into the con, believing that we are somehow capable of feats no one else can do.

Sometimes that’s allowed, even expected – not everyone can perform brain surgery or resuscitate newborn babies – but other times we overreach. Doctors frequently pull stunts like trying to function normally after 36-48 hours with no sleep. We sweep treatable issues like depression under the rug because of course we can handle it, self-medicating with substance use or else ignoring the problem entirely until it can no longer be contained.

The medical profession carries one of the highest rates of suicide (1.4-2.3 times the rate of the general population). But discussing an issue that can call into question your fitness to practice is absolutely off-limits. In the most ideal and ethical situation, doctors would put the patient’s interest ahead of their own security, but we are human first, driven by the same fears and needs as everyone else. And there is a very real fear that any perceived disability will end or permanently blight our careers.

On top of this is the associated stigma of mental illness that is so very rampant in Jamaica and the Caribbean. No patient wants to see the “mad” doctor who “tried to kill himself”. But if any progress is to be made in erasing this stigma we physicians have to be the pioneers. And since this stigma persists even among doctors, we are the first hurdle we have to clear. After that, education and sensitization of the wider society.

Even though no one seems ready to talk about it* (Megz over at Barefoot Medz is one of the few, doing a really great job) mental health is a discussion we need to have. In such an emotionally draining and psychologically demanding profession it isn’t fair to anyone to have doctors fumbling to look after their mental health alone.

We need to catch mental health issues among physicians from early, as early as medical school even. Mandatory psychological screening for depression, anxiety and PTSD among others should be instituted for all the high risk professions: doctors, police officers, firefighters. We shouldn’t have to wait until a doctor commits suicide or a policeman kills his spouse before doing something. Prevention or at least early detection is paramount.

There’s a lot of work to be done. Efforts have started but they’re halfhearted at best and the government offers little in the way of support. We must be our own advocates and work with other key players to remind the public that there is no good health without good mental health.

*

Further reading: a pediatrician’s experience with psychosis, and a GP’s experience with depression.

*After writing this post, I discovered Dr. Eric Levi an ENT surgeon who is also making strides in the discussion on mental health in doctors. 

Nepotism, hamster wheels and career-sized roadblocks

Robyn, , , , 4 Comments

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.

Reframing Misconceptions

Robyn, , , , , 5 Comments

I make a habit of naivety.

Not always on purpose, but often enough that even my super-oblivious brain has recognized the trend. In his more romantic moments, my current partner says that my optimism is the perfect antithesis to his cynicism. In less romantic moments, he expresses great concern about my intelligence.

Running headlong and heedless from hospital medicine into primary care with the half-baked hopes of “fixing Jamaica’s healthcare problem at the source” will not rank highly in my self estimation. And it was silly of me to think for a second that the only thing broken was the almost universal lack of health education among Jamaican patients.

I will probably never know how wrong I was, because I will probably never fully comprehend the multiplicity of the flaws afflicting the delivery and reception of our healthcare. From patient contact to policy making, I think there are a myriad of ways for either the system or the client to fail each other.

This is where my optimism wanes. I doubt myself. It’s one thing to be exasperated by a  health illiterate patient in the emergency department, mentally berating primary care doctors for not taking the time to have proper dialogue with their clients. It is quite another thing to be confronted by climbing physician:patient ratios, dwindling consultation times, and perhaps the most frustrating of all: repeat offenders. The patients who, despite adequate counselling and interventions, persist in their unhealthy behaviours.

Cynicism rolls in like a dark cloud, closely followed by the lightning storm of burnout. The horizon of my imagined clinical nirvana (where patients and physicians work together to help patients live longer, better lives) all but disappears.

And yet.

The dream of an effective and efficient health care system isn’t inherently stupid. Yes, I was foolish to think I could effect change just by wishing for it hard enough, but the bottom line is that change needs to be effected. And the nugget of reality at the core of my fantasy is the desire to be a part of that process.

If I just re-frame my ideas of how exactly health care reform will happen (a lot more meetings and red tape, and a lot less glitter and fairy dust), the cloud of cynicism drifts out of sight. It will be longer, more tedious and may not turn out quite the way I expect (like most adult dreams) but that is okay. I don’t have to throw away the dream, I only have to take it down from that lofty shelf and actually work at it.

It would be easier to be cynical.

The Unfortunate Business of Death

Robyn, , , , Leave a comment

Breaking bad news at one in the morning
Is not part of the prescribed medical school curricula
Real life has no point score for empathy
Patience
Directness
But conversations twist as they need
And break when they must into tears
Screams
Silence
Five minutes.
(Is an exam, not the ending of a life)

What to Expect when You’re Interning

Robyn, , , , , 4 Comments

Internship starts, not with a bang or a whimper, but with a barely noticeable intake of breath. Not a deep breath, a regular resting one. You don’t notice it until you do. That’s the only excuse I have for why there are no entries in my journal until six whole days into my intern year. I will attempt to recreate those first few steps now.

If you’re completely unfamiliar with internship in Jamaica, here is a brief overview. If you already know everything there is to know, feel free to skip this next paragraph.

When medical students graduate from UWI they have already applied to work at one of five several government hospitals (and one semi-private hospital) qualified to supervise medical interns. What follows is a 12 month long, somewhat supervised trek through the four basic clinical specialties: General Surgery, Paediatric Medicine (babies), Internal Medicine (adults) and Obstetrics & Gynaecology. This experience is unique to each hospital (and each intern), but overall we’re expected to emerge from this year with the skills necessary to become a fully licensed medical practitioner. (Don’t worry, nobody tests you on these skills. Which is probably why so many bad less than stellar doctors slip through the cracks).

At my hospital, we received a one day orientation the week before we were scheduled to start working. I think this is the standard. We were introduced to key members of staff (bureaucracy, meh), discussed the housing situation (lacklustre at best), were given a tour of the facilities (too big to walk around without getting tired) and then spent two hours delving into grim and gory details of everyone’s favourite topic: remuneration.

Predictably, the session left us entirely unprepared for the actual first day on the job.

I started my internship in General Surgery and I remember feeling small. Not unimportant, just literally small. Like a child. In final year, patients would laugh when I approached them for procedures, asking if I was still in high school. And here I was not six months later as their doctor, their first point of contact with the surgical team. My first ward round passed in a blur of unfamiliar names, familiar diagnoses and trying to sign my name quickly enough to move on to the next docket.

It got easier. Those patients who were handed over to me left. I got my own patients. My handwriting got quick (and sloppy). I became familiar with the system through trial and error. I asked questions, I did things the wrong way, bore the scolding with chagrin and did it properly the next time. I learned how to brush off the rudeness that you encounter on a sometimes daily basis, grit my teeth through collecting and administering medications (because this is not my job*), learned how to smile the right way to get a porter’s help**, and how often to call the radiology  department to actually get my patient’s goddamn x-ray.

If you ask me (and you are asking me), those are the skills an intern needs to learn and learn quickly. Your medical acumen is already there, you’re already familiar with every procedure they expect of you (it is okay to need supervision; my point is you’ve heard of or seen them all before). What you need to survive is the knowledge of how to navigate the complex social and professional sphere that is the tertiary medical facility. How not to step on toes, when to step on toes, what the unwritten protocols are and how to use them to your advantage (hint: they mostly involve doctors’ egos). I could write a book on helping the fresh faced med school graduate survive, a pocket-sized guidebook probably, but a book nonetheless. Yet here I am, giving it away for free. (I’m tucking this idea away for my first book though. Obviously).

From my viewpoint , having completed almost 75% of my internship I can tell you unequivocally that at some point you will fuck up (the scale of fuck-up varies widely and depends entirely on you). You will feel like you’re the worst, most incompetent intern that ever interned. And then you’ll survive Paediatrics, and you will feel like you can conquer the world. You’ll reach a point where it gets better and you’ll survive this are’t just aphorisms any more, they’re universal truths. You will surprise yourself.

Unless you quit halfway through. And that’s okay too! It’s better to figure out from early that you hate this job and run away to  rob run a bank somewhere. Everyone isn’t for Medicine and this is fine.

The first part is hard, and the middle part, and I think the bit at the end is going to be hard too. Every three months you start over, start learning something else. Carry the good lessons with you, drop the bad habits and keep your wits about you. If all else fails, remember, it’s only twelve more months***.

_

* Here I feel obligated to add that helping patients get better is my job. And if that involves getting their medication, mixing it, administering it, wheeling them down to x-ray or up to operating theatre by myself while manually ventilating so their oxygen saturation doesn’t fall below 95% then that is what I have to do.

**Before anyone gets into a feminism/sexism snit I would like to point out that each gender has its advantages in the hospital hierarchy. The guys get nurses and other female staff to do any and everything for their patients just by flexing a bicep. Therefore I am not above using my femininity to get shit done.

***Unless you’re a foreign-trained intern who failed their CAM-C exams. Then you could be here for a long, long time.