The Medicine: A Doctor's Notes

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When the Doctor Needs a Doctor

Early Friday morning, I got cancer. Bad cancer, the kind that can colonise your bones. Mine had spread to one bone in particular: a rib in the middle of my chest. To diagnose myself I took a history, questioned myself about the nature of the pain and did a physical examination. The pain woke me up, it was grinding and rated seven out of ten when I moved or breathed. There was point tenderness over my fourth rib just medial to the mid-clavicular line, and crepitus (a distinctive crackling feeling when shards of bone grind together). The invaded bone curved right over my heart’s left ventricle. A terrible click vibrated through my chest whenever I took a breath. Given that I hadn’t fallen from a ladder, I knew this was a pathological fracture: one caused by something bad happening inside your body, such as spreading cancer. I lay down on the lounge room floor, staring at the ceiling, wondering if it was a breast or lung primary, and how many months I had left. Then I called my workmate Harry.

I’ve had a lot of diseases over the years – Hashimoto’s thyroiditis, hepatitis, a ruptured spleen and multiple episodes of lymphoma – with peak incidences around the time of my final med-school exams and then, six years later, the specialist exams. There are millions of diseases, and a body can generate a kaleidoscope of sensations: who’s to know for certain if the pain in your gut is the result of too much hummus and not actually a huge tumour in your pancreas? Who can know for certain without having a long, hard look at your internals with a high-resolution scanner?

There’s talk in the media and around the wards about over-investigation. That is, looking for a disease that is highly unlikely to be present. Take lower back pain, for instance. Each year Australia spends about 220 million Medicare dollars on X-rays, CT and MRI scans for lower back pain. Most people experience back pain at some point in their life, which makes back pain normal. Though normal, pain makes us anxious: we want to know why we are feeling it, if it is a sign of something dangerous, something that may leave us permanently incapacitated. After all, every nerve that allows you to move and feel your body travels through the spine; what if one of the bones has moved and compressed a nerve? So you go to the doctor, who engages you in a strange dance: she raises your leg, asks you to bend it, presses and pulls, taps your knees and ankles, bounces a pin across your skin. All good, she says. Heat packs and paracetamol, and don’t take to your bed, she says. Your heart thumps. You had pictured severed nerves, surgical interventions; your future in a wheelchair. And in the face of all this she asks you to trust her tendon hammer?

There are clear international guidelines outlining the limited circumstances in which it is appropriate to scan a patient with back pain. If we followed these guidelines we’d spend only a fraction of that $220 million. But we don’t. Health economists, researchers and politicians wag their fingers, cry waste, and then chuck their reports in the air. Why won’t we listen?

But, you say to your doctor, "what if …?" Anxiety courses from your eyes into hers, which for a microsecond display the tiniest flicker of uncertainty. You grasp your flank. Maybe you feel your left foot tingling. She looks from your right eye to your left to your right, wondering if she trusts her tendon hammer, remembering that one case that one time. The most powerful anxiety-relieving item on the market is not Xanax. The most powerful anxiety-relieving item available is a high-tech scan.

I open a detailed illustration of chest anatomy on Google to check that I haven’t neglected any possible sites of disease, while Harry and I consider the differential diagnoses over the phone. We come up with a fractured bone or a separation of the cartilage and rib.

You probably did it rowing, he says.

How do you know?

Because you row.

As I’ve advised dozens of patients over the years, if you break or dislodge a rib there is nothing to be done except swallow painkillers, apply ice packs, and not row, swim, run or lift heavy objects until the bones re-knit. I reassure myself, and follow my own advice, for a day. Then I order an MRI.

In my defence, the scan is – quite rightly – not covered by Medicare, so I pay for it in cash. As punishment for over-investigating myself, the tech makes me lie rib-down on the scanner bed for the entire thirty minutes.

A magnetic resonance scanner is a gigantic humming electromagnet that spins and excites all of the hydrogen nuclei in your body. Then it lets them relax, and turns this into images. The magnets generate sounds much like a painfully loud industrial experimental garage band. Unlike X-rays and CT scans, there is no ionising radiation exposure involved in MRI. You’re just bathing in an incredibly powerful electromagnetic field, having your atoms manipulated for half an hour.

The problem with increasingly sophisticated medical investigations is that they sit in their expensive suites like coin-operated gurus. We know they’re in there and they can tell us the answer to everything, even the things we already know, don’t need to know or would be better off not knowing. So it’s helpful to be able to tell a patient that I don’t think they need a test, and neither does Medicare. It’s like trumping an argument with Because Mum says so. Some patients, however, stubbornly resist their doctor’s reassurance.

I get dressed and go backstage, where the radiologist sits in front of a bank of screens, searching for anatomical anomalies. He shakes my hand and then points his mouse to the aberrant gap between my fourth rib and its cartilage. Despite the fact that I’d made no mention of cancer on the request form, he smiles and says, knowingly, Rest assured, there’s no sign of any underlying mass.

Please, Go On

The minute I was accepted into medical school I became, in the eyes of my friends and family, a professor of every clinical specialty, with a sideline in veterinary medicine. The calls started almost immediately. Overnight, I transformed into that respected (if occasionally lethal) person in the medieval village who had no training but was somehow the one everybody went to for treatment and counsel. I had a new authority I hadn’t earned, didn’t want and (despite anxious protestation) couldn’t negate.

After I graduated it became trickier to cry complete ignorance. Saying I didn’t know turned me into an object of contempt. It’s difficult to know and harder to be right about a clinical scenario related by email. A few years ago a particularly hypochondriacal family member (who only calls when she has a medical concern, usually a single episode of diarrhoea) thought she’d broken her little toe. Terrified, she told me the story and symptoms. I said it probably wasn’t broken, but even if it was she wouldn’t score a cast, and that she should just be gentle with it and it’d get better by itself. She sounded doubtful. I reassured her. Her doubt escalated. Well, if you’re worried, I said, maybe go see your doctor? Later that day I received an SMS – no words, just a photo – of an X-ray of her foot with a big red arrow pointing to a tiny cracked bone. I could feel it so sharply, her contempt.

When my siblings had children, my task was to advise – from interstate, over the phone – about the need or not for their infant to be hospitalised. I’d listen to long, rambling stories about mucus and vomit and what might be a rash and someone they knew who knew someone whose kid was just like this and was reassured by their doctor and the kid ended up in intensive care, almost dead. For a very junior doctor who’d never laid eyes on a sick child, these calls were a source of great distress. I’d listen, my mind screaming unspeakable words, words like meningococcal meningitis, acute lymphoblastic leukaemia and osteosarcoma. I’d say, Does he have a fever? They’d say, Hold on, and come back and tell me his forehead felt hot. Everyone’s forehead feels hot. Everyone’s throat looks red. How else would we score days off school? I bought electronic thermometers for all my family members and told them not to call me without a readout. I completely understood their impulse to call me and probably would’ve done the same. I do do the same, to my friend Mike, a very experienced physician in his late sixties. In the past few months he’s talked me down from a self-diagnosis of imminent diabetes (because I found a tiny skin tag) and melanoma (that was a blood blister), and he stopped me getting an MRI for my achy, post-workout knee.

If you’re planning on having a doctor in the family, I recommend a general practitioner. One of their greatest skills is the ability to triage the mournful from the sick. And the sick from the sick-sick. Without a full set of obs, a battery of blood tests and an X-ray or two, hospital doctors like me aren’t very good at that, especially not early in our careers. Picking the sick from the sick-sick is the most useful talent a family-member-doctor around the dinner table or on the end of a phone can have. Quiet, febrile, floppy and anuric (not passing urine) is emergency-department bad. Screaming and snotty is probably a-trial-of-paracetamol bad.

I know that these phone calls and corridor consults are not recommended practice. And I suppose that technically my every response should be Go see the GP, but rules and recommendations often get bent and broken for good reason. My brother, for instance, lives on a farm a few hours’ drive from after-hours services and has a son prone to asthma. Advising him and his family to drive to the city and wait half the night in the busy emergency department each time he called would be an outright abandonment of my sisterly duty. I know him. I know the kid. He finds running it all by me to be helpful.

Unlike my family, my friends and acquaintances always apologise profusely before they ask me anything medical. And afterwards they are grateful to a degree I never deserve. Sometimes they just need to know what kind of doctor they should call, what the word on the street is about orthopaedic surgeon Mr Such-and-Such, whether wanting a second opinion sounds neurotic, if I know a good geriatrician north of the river. I’m usually of no material help at all. I’ve faxed the occasional referral, written a script or two. It is the very rare occasion where my knowledge, connections and my friends’ needs align.

Strangers mention their aches, pains and troubles obliquely, or in tiny flickers, all the time. They’d quite like to tell a sympathetic ear, and I can’t help myself, I love it. Yesterday the supermarket cashier had sore and poorly healing teeth with CPAP mask complications, the elderly man next to me in the queue at the post office had a sick wife (long story) and catastrophic house fire (longer story), my daughter called me from camp with a headache (pressure from the snorkel mask she’d had on all day), and her best friend needed advice about dressing her cut foot. A medical degree doesn’t confer authority so much as dissolve the line between a polite story and what my daughters would call TMI. Get a medical degree and nothing is ever again Too Much Information. The apologies are unnecessary. None of it is onerous or burdensome: to listen, even without all the answers. I invite it – often quite literally. It’s the position I’ve adopted, how I feel part of the world. I’ve been insatiably curious about sentience since childhood, but now my Please, go on face isn’t weird and creepy and strangely over-freckled; it’s something approaching trustworthy. Doctorly, if you will.

Ironman and Medical Exams

Around Australia the registrars are about to sit part one of the medical specialist exams, the rigour of which makes medical-school exams seem like hopscotch. I feel sorry for them: five years on the wards and now trapped inside cages of heart-thumping ignorance. Physicians in their eighties still have nightmares where they’re forced to repeat the exams. I sat them in 2008 and sacrificed a year to that relentless act of endurance. I stuffed myself so full of facts that eating made me sick. I listened to recordings of the review lectures as I drove to work, as I jogged and showered. I sat with summaries in front of my face while my family played; I littered the house with Post-it notes that described pathways and diagnostic criteria. For a year I didn’t glance at a newspaper or a novel or a movie. Like an obsessive-compulsive loop, my every thought ended with the same punctuation: Must study. When it was all over, my reams of notes packed in cardboard boxes, I walked through air without gravity, each thought now ending in a cliff dive.

After the exams I had to choose a sub-specialty and train for a further three years. Unsure of what I wanted to do, I took a last-minute advanced-training post in nuclear medicine. I was plucked from hectic inpatient wards and dropped into a sleepy office where I rarely saw a patient in the flesh, except to tattoo the skin above their sentinel lymph node moments before the surgeons hacked out a tumour. Mostly I sat behind the boss’s shoulder, trying to decipher ghostly scans. All those years of study, of smacking up against the raw humanity of the desperately ill, so I could sit in a padded chair in a dark room.

We interpreted images of limbs and lungs and entire bodies riddled with black spots – cancer, infection, broken bones – using rote phrases. In the tearoom, the technicians who operated the scanners talked about something called ironman, an event where they voluntarily paid big money to swim 3.8 kilometres, then cycle 180 kilometres and then run a full marathon (42 kilometres). Why? I asked them. "Why?" They shrugged, lifting salad sandwiches to their mouths, tight biceps flexing beneath polyester uniforms, chewing with cut jaws. They talked training hours, diet, drills, PBs (personal bests) and squads. My legs started to twitch. One second I was thinking they were a bunch of monomaniacal psychos with rather pretty bodies, the next I was buying a waterproof, heart rate–monitoring GPS wristwatch. I got a coach. He wrote me a training program that read like a job – two sessions a day, twenty-two hours a week – and I felt a deep relief.

I’d rise at 5 a.m., drive to the Olympic pool and join my squad. In the fast lane were the semi-pros and the coaches, guys with tattoos of the Southern Cross and the ironman symbol, cutting through the water like sharks. I swam with skinny boys, tough girls and a 65-year-old woman who once finished an ironman event with her foot dangling from her ankle like a flag. She’d severed a tendon at kilometre 22 of the run. It didn’t hurt, she told me. Only the partial tears hurt.

After work I’d go to sprint and hill training, or on long solo runs. I bought an Italian bike, light as a bag of flour. I rode with a peloton of men until I grew tired of their chitchat and went out by myself, riding for hours along the fine line that divides effort and pain, my cleats clipped into titanium pedals, trucks beside my elbow, thinking of nothing except how far I’d come, how far I still had to go.

In the squads I was no one; I came from nowhere. People who didn’t know my last name or my job knew I was gaining on them by the character of my footfall, could recognise me by the colour of my bike. We were a strange sort of community, linked by what we were forcing our bodies to do. You didn’t have to be fast; you just had to keep going. I spent my spare time adding up hours trained, kilometres covered, grams of protein consumed. I studied textbooks of exercise physiology and triathlon magazines. The techs and I DEXA-scanned our bodies to learn the precise percentage of muscle and fat we carried. We diagnosed each other’s kaleidoscopic aches and injuries. I tried to calculate the physiological age of my 35-year-old heart: I pushed myself to my maximum (196 beats per minute) and ended up facedown in the grass, misbeats racking my chest. You can mine a lot of data from your body when you’ve got nothing else to study.

I raced a half ironman alongside Tony Abbott and beat him by an hour. I raced the Australian long-course triathlon and qualified for the amateur worlds. I’d have to train harder, but I’d get my own racing suit with a golden Hitchcock printed across the green arse. I was right in there, wet and steaming and laughing along with all the other biceps and quadriceps, the wetsuited, kickboarding swimmers, the aerodynamic riders and the high-tech runners. And then one morning I stood at the edge of the pool and felt a sick sort of shock: I stared at those people – my squad – and they seemed in that moment a collection of exotic, curious and utterly anonymous creatures in an aquarium.

I quit the squad and my job and started training as an acute and general medicine specialist. Ironman had been nothing more than an elaborate, frankly exhausting way of moving from the exams back into life.

The Gentlemen’s Club

Every hospital has a residents’ room. A place only the junior doctors can enter, where posture and politeness are discarded, naps are stolen, bosses are demolished, hook-ups are arranged and black humour reigns. It’s like a pub without alcohol.

I transitioned from trainee to boss in the same hospital. Overnight, I was barred from the residents’ room and granted entry to the consultants’ room. I called it the gentlemen’s club. It had chesterfields, old portraits, a cupboard full of (unopened) top-shelf liquor. I’d go there to open my mail. It was mostly deserted – just the odd professor or two sitting at opposite ends – but somehow the toilet seat was always up. And though I’ve never been one to engage in the toilet seat wars – he puts it up, I put it down, seems fair to me – for some reason I started to read this one as a fuck you.

Female medical trainees now outnumber male ones. Behind closed doors this is bemoaned as a feminisation of the medical workforce. A phenomenon that will lead to decreased productivity due to all that child rearing. To less doctoring per medical degree.

I’ve had countless corridor conversations with female registrars – pre-exam and post, partnered and not – about the best time to have children. They approach me nervously, look around to check no one’s in earshot. When did I do it? How? I fell pregnant with twins in my second year on the wards. I planned to take eight weeks’ maternity leave, and come back as a registrar to start the six years of specialist training. The huge regional hospital I worked in was enormously supportive of me as my belly swelled, slotting me into the less acute units such as geriatric rehabilitation. After the birth they extended my maternity leave, then let me job-share with another kid-wrangling registrar. They saw no problem with me running out to the emergency department’s drop-off zone every four hours to breastfeed in the passenger seat of my partner’s car. This kind of flexibility only exists in places battling a workforce shortage. If there’s a line of equally qualified people snaking out the door, who’d negotiate? I know a doctor who received a phone call on the eve of her specialty interview, telling her not to bother because she was pregnant. Outrageous. But imagine you’re hiring a trainee for a twelve-month position. The job is arduous. The more work they do, the further into the year they progress, the better they get, and the less you worry about your patients.

There are exceptions, but most heads of departments are men getting on in their years. They are married to women who raised the children and kept the home. This arrangement remains quite common among the younger male hospital specialists, and brings with it a particular kind of ease: last-minute after-hours meetings and early start times – things that put me into hypertensive crises – won’t orphan their children. And yet, at least five times, I’ve heard male doctors joke that their wives won’t let them retire: I’d drive her crazy. I’d get under her feet. I’d leave crumbs on her benchtops.

Periodically, the various specialty colleges form committees to address structural sexism: the lack of flexibility in work hours, the discrimination against the pregnant. The committees peter out or draft idealistic recommendations using words like urgent and imperative. But it’s all a show. What department would choose complication and distraction over insouciant dedication?

We could change structures in the hospital to make it more family-friendly. Have the wards crank up after school drop-off rather than at 8 a.m. Mandate that a decent proportion of the training positions are part-time. Offer paternity leave. In-house child care. Perhaps