WE RUN THE NIGHT: an ode to hospital night-shifts

I just completed my 7th night-shift in a row.  It may have been the post-nights delirium setting in, but I found myself reflecting wistfully on the strange, scary and unique experiences a hospital night-shift can provide. What else to do, but write an ode to night-shifts, and the staff who keep the hospital alive overnight?

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Now I’ve used up all my delirious creativity, it’s back to bed to recover. These night-shifts are doing me in! I’m training for my Diploma in Obs & Gyn, and it’s been an interesting experience to re-enter the hospital after a few years in General Practice. Makes me glad I’ve chosen a career that can be 9-5 if I want it to be. More frequent posts promised when I’m back doing a day job in GP!

A Little Story About Postnatal Depression

This week, September 12 is R U OK? day, reminding us to check in regularly with family and friends and support those who are struggling. I thought it only fitting to write a mental-health themed blog.  Australian Doctor magazine recently held a short story competition entitled From Where I Stand, and while I wasn’t the winner, I was happy with my little tale.  I should point out it’s fictional, a blend of stories from women I’ve treated over the last few years. I hope you appreciate it too. 

——

I sit on the ground next to her, on the cold concrete outside the hospital wing. She’s sobbing, hunched in a tiny ball, clutching her chest like it’s the only thing keeping her from falling apart. She thinks she’s failed.

She came to see me in my clinic this morning, two rowdy kids and a three-month-old baby in tow. Dark circles under her eyes, a slight tremble in her hands. Eyes flicking everywhere like a hunted animal. “He just won’t stop crying! I don’t know what else to do!” It’s the fourth time she’d seen me in a fortnight, each visit a different, minor thing, and my alarm bells were ringing.

I ask her how she’s doing, leaning in, giving her my best ‘I’ve got all the time in the world’ look. Our eyes lock, her chin trembles with a brief hesitation, then a brush-off as she glanced away. “Oh, you know, just sleep-deprived I guess.” She snaps at one of the kids as they ransack my drawers. “I’m alright.” She visibly gathers herself in the chair. I try again, “It looks like you’re having a really hard time.” Then her eyes brim with tears, against her volition. And the floodgates open.

Her five-year-old daughter starts crying because Mummy’s crying. Her seven-year-old puts his serious man-face on, and looks to me for help. We comfort her together (he pats her on the knee) as a few distraught sobs break loose. I ring for the practice nurse, who takes the kids for a biscuit and some distraction “while Mummy talks to the doctor.” The five-year-old is won over by the bribe of sugar, but her little man leaves us warily, glancing back over his shoulder as he’s towed outside.

I want to explore things further with her. I want to see how far down the rabbit hole she’s fallen. I start with easy questions to break the ice, and push my box of tissues in front of her.

She’s never been like this before. Usually she’s pretty happy and well. Her partner is trying to establish himself as a dairy farmer and he works long hours outside the house. She’s cooped up with the kids all day. They moved interstate for this chance two years ago, leaving her family thousands of kilometers away. They live forty minutes from town, and it’s not worth the effort of packing up three children just to drive in for a mother’s group – she can barely manage a supermarket trip.

This baby, things have been different – and it began with the birth. He was facing the wrong way, so she had to have a caesarian. She was sore for weeks, longer than she expected. Her milk came in late, and this baby doesn’t seem to feed greedily like the others; he’s been fussy from the start. She’s been secretly topping him up with formula because everyone kept commenting on his skinny little arms. She felt dreadfully guilty doing it, and avoided the child health nurse because she was afraid of being told off. She’s read all the books, she was desperate to breastfeed – but after three months her milk’s dried up, and every time she makes a bottle of formula for him she feels like a failure.

And now the colic! Every evening now the screaming starts. Three solid hours of inconsolable, purple-faced baby. Right when she’s trying to make tea for everyone, and put the kids to bed for school. Her husband comes in exhausted from the milking sheds at 7pm, expecting dinner on the table before he rolls in to bed and crashes for the night, ready for his 4am start the next day. She knows he’s stretched thin too – dairy farming is exhausting, especially a one-man outfit like theirs – and she feels like she’s letting their team down if she can’t even keep control of the household.

She hasn’t told him she’s struggling. If he tries to help, to take over some duties, she sees it as a criticism of her abilities. She feels ashamed. Why is it so much harder this time? This baby wakes constantly through the night. She’s so sleep-deprived; she can’t even be bothered to get out of her pyjamas most days. The house is a pigsty. The kids are being sent to school with coins for lunch. She hasn’t been to the hairdressers since halfway through the pregnancy. She hasn’t shaved her legs in a month. She feels fat, unsexy, useless and worthless as a woman and a mother. She wouldn’t be surprised if he doesn’t love her anymore, who would?

I prod a little deeper. I’ve noticed that through this entire consult, she hasn’t made eye contact with her baby. When he whimpers, she rocks the handle of the carrier. When he squawks, she picks him up roughly and pats him over her shoulder, until he stops and she puts him back down. I can see he’s mouthing and chewing his fists; he’s clearly hungry. She doesn’t seem to notice.

“When the baby’s driving you mad and you’re at the end of your tether, you can feel really angry. Does it get like that sometimes?” She hurriedly nods, relieved I’ve put it out there. “Some women even think about hurting their baby – slapping it, or shaking it. It doesn’t mean you’d do it, but has the thought occurred to you?”

This is what she’s been waiting for, to tell someone this dreadful, shameful secret that’s eating her up from inside. Her voice drops into a whisper, tears spill down her cheeks and she admits that sometimes, she wishes he’d never been born. Sometimes she has to stop herself from slapping his chubby little thigh when he’s screeching uncontrollably. Sometimes when he won’t stop screaming, she won’t pick him up, because she’s worried she’ll shake him like a rag-doll if she does.

Two nights ago, in the dead of night, she thought about ending her own life. She was up yet again with the baby, her husband was asleep. She’d take the baby with her. Something gentle, like car exhaust, where they could both slip away into sleep. Her other kids would probably be better off without her since clearly she’s not fit to be a mother.

We’ve reached the crux of the consult. She looks fearfully at me. She’s exposed her soul, put it out there for judgment, and she’s instantly regretful – yet at the same time, she’s desperate for someone else to take the burden from her. Shame and guilt radiate off her in waves. “I think you’re having a really, really hard time of it. I think you have postnatal depression. And I’m worried for you. I think we need to help you, fast. What would you say to a short stay in hospital, a bit of R&R?”

I’m lucky, you see. I have admitting rights to my local hospital. And what I think this woman needs first and foremost is sleep, as well as recognition of her predicament and pretty urgent help. My practice nurse and I arrange the details – call her husband to explain, ask him drop off clothes and take the kids home, while I run her case past some experts over the phone.

This is how we’ve come to be sitting on the concrete outside, later today. I find her here, freezing in the cold, after discovering her bed empty on my evening rounds. I pat her on the back as the deep sobs choke their way out of her. I sense a catharsis, a release, in their violence. She’s been trying to keep it all under wraps, under control, not letting anyone know for so long. And now, of course, everyone will know. She’s not sure how she feels about that yet. I help her up; we wander back to her room and talk.

We talk about how these things she’s feeling – guilt, shame, worthlessness – are all part of postnatal depression. I explain that many women in her place have similar thoughts of hurting their baby, or hurting themselves – it doesn’t mean she’s a bad mother, it means she’s very, very unhappy. I tell her we can help her, and we’ll make plans in the morning once she’s rested. But for now, we’re going to send her off in a chemically-assisted snooze until morning.

A last shuddering sigh escapes her as she climbs under the covers.  She looks down at her hands. “Thanks for listening… I must look like the worst mother in the world right now.”

“Not from where I stand.”

TEN SIGNS YOU’RE A GEN Y DOCTOR

I’m taking a guilty break from my GP exam study, so it’s a brief blog from me this time.  How do you recognise a Gen-Y doctor? Let me tell you, as I sip my fair-trade chai latte and touch-type on my MacBook Air:

1.  You’ve actually used the word ‘chillax’ in a consultation.

2.  You’d like to save the world – but only if you can do it part-time. How else will you manage your eco-solar-chookshed and your sustainable-organic-vegetable patch?

3.  You play Words With Friends, not Sudoku, while you’re anaesthetising patients.

4.  The administration staff are amazed you can plug in a LAN cable. Or fix the printer. Or touch-type. Or, heaven forbid, SEND A FAX YOURSELF!

5.  You’re planning a Locum Odyssey that entails surfing/working around the country for a few years. YOLO!  (Also, you know what YOLO means.)

6.  You’re not going to hang your diploma on your clinic wall. You’re going to hang photos you took on your DSLR of your hot-air-ballooning adventure over Myanmar, or your trek through the remote Nicaraguan jungle, or your windsurfing tour of the Maldives…

7.  You consult the Twittersphere, not the library, to find out about the most up-to-date medical research.

8.  You’re considering early retirement after 3 years of full-time employment.

9.  You’ve never seen a case of Smallpox. Or Polio. Or TB, Measles, Diptheria, Tetanus… or pretty much any vaccine-preventable disease. (Unless you live in Northern NSW, that is.)

10.  If the Internet shut down, you might not remember how to be a doctor.  See, you haven’t bought textbooks, because they go out of date before they hit the shelves these days. (Scary thought, that one…)

That’s all for now. Back to the books… Or should I say, back to my online subscriptions, FOAMed and RACGP website tutorials?

MODERN MEDICINE: A CENTURY OF PROGRESS? George Bernard Shaw’s 1906 ‘Dilemmas’ hold true

George Bernard Shaw was a very clever man, and he wasn’t too fond of doctors. The Irish playwright penned The Doctor’s Dilemma, a sometimes scathing, sometimes sympathetic reflection of Modern Medicine circa 1906. Having shamelessly stolen the off-copyright title for my blog, I thought I better pay tribute to his fascinating insights, and ask the question – have we made much progress in a century?

 While the play itself is certainly insightful, the preface is pure gold. I’ll share some of my favourite George-isms, though I’d highly recommend reading it, as a humbling exercise for the modern doctor. It’s a poignant reminder of the historical (and sometimes current) follies of our profession.  Let’s start with:

   “The demands of this poor public are not reasonable, but they are quite simple. It dreads disease and desires to be protected against it. But it is poor and wants to be protected cheaply….What the public wants, therefore, is a cheap magic charm to prevent, and a cheap pill or potion to cure, all disease. It forces all such charms on the doctors.”

 As a man of science, George lamented the lack of scientific rigor amongst medical men of the time. He thought doctors too often were caving to the public’s push for such magic charms.

   “They are not trained in the use of evidence, nor in biometrics, nor in the psychology of human credulity… Further more, they must believe, on the whole, what their patients believe… When the patient has a prejudice the doctor must either keep it in countenance or lose his patient.”

The dilemma of challenging your patient’s beliefs (at the risk of losing the therapeutic relationship) still applies – as any GP who has refused antibiotics for a snotty child will attest to. It’s also important to point out a common folly still committed today;

   “Doctors are just like other Englishmen: most of them have no honor and no conscience: what they commonly mistake for these is sentimentality and an intense dread of doing anything that everybody else does not do, or omitting to do anything that everybody else does.”

He was concerned that doctors of the time sometimes exchanged scruples for cash, particularly while working as sole traders whose livelihoods depended on their popularity. Remember, of course, that doctoring was a lowly-paid profession in 1906.

   “Private medical practice is governed not by science but by supply and demand; and however scientific a treatment may be, it cannot hold its place in the market if there is no demand for it; nor can the grossest quackery be kept off the market if there is a demand for it.”

George lived through the era of emerging germ theory, and watched it shape the profession. I think this statement holds more merit than any other he penned, particularly on the effect germ theory had on our modern paradigm of disease/cure – and the often-times overlooked art of healing.

   “We are left in the hands of the generations which, having heard of microbes much as St. Thomas Aquinas heard of angels, suddenly concluded that the whole art of healing could be summed up in the formula: Find the microbe and kill it. And even that they did not know how to do.”

Too true, George – and what would a scathing review of the medical profession be without some reflection on doctor’s egos, or self-righteousness? At times, it can feel we haven’t come that far in a century…

   “Make it compulsory for a doctor using a brass plate to have inscribed on it, in addition to the letters indicating his qualifications, the words “Remember that I too am mortal.”

    “The surgeon, though often more unscrupulous than the general practitioner, retains his self-respect more easily. The human conscience can subsist on very questionable food. No man who is occupied in doing a very difficult thing, and doing it very well, ever loses his self-respect.”

George did cut us a little slack though, towards the end. He honoured the selflessness of the medico in attending people in their hour of need, particularly the country GP.

    “When the baby is suffering from croup, or its mother has a temperature of 104 degrees…nobody thinks of the doctor except as a healer and saviour. He may be hungry, weary, sleepy, run down by several successive nights disturbed by that instrument of torture, the night bell; but who ever thinks of this in the face of sudden sickness or accident?”

    “Every general practitioner is supposed to be capable of the whole range of medical and surgical work at a moment’s notice; and the country doctor…often has to tackle without hesitation cases which no sane practitioner in a town would take in hand without assistance.”

I believe (and hope) we’ve made some progress since 1906. Particularly in evidence-based decision-making and professional transparency, to help remove the public’s doubt that our decisions might be based on a financial interest in our patient’s ill health! At times though, the culture of ‘find the microbe and kill it’, and ‘doing what everyone else does’ doesn’t appear to have changed much in a century. Something for us to work on, perhaps?

Thanks for your eternal wisdom Mr Shaw, and may it continue to give pause to many more generations of doctors ahead of us.

GOT COMPASSION FATIGUE? DOC, YOU’RE HEADING FOR BURNOUT

I’ve noticed a concerning trend amongst my hospital registrar colleagues lately. Put them together after-hours, and there’ll be callous, cynical sniping at anyone within their firing range – patients, nurses, and other colleagues.  I know for a fact they are caring, compassionate people. I also know they’re under-supported, over-worked and emotionally exhausted. And I worry they’re burning out.

A little black humour never fails to blow off steam, and it can be a healthy way to acknowledge and relieve some of the emotional burden carried by the caring professions. But at what point does it become unhealthy, and would you recognise it?

Empathy Fail (unable to credit this gem - found it on a twitter feed with no artist reference)

(unable to credit this gem – shared on Twitter with no artist reference)

 Try my BURNOUT QUIZ

  • Are you often negative, cynical or sarcastic about your patients and colleagues?
  • Do you feel like your patients or colleagues are deliberately trying to drive you crazy these days?
  • Do you expend all your energy just surviving the work day, and crash when you get home?
  • Do you dread going to work, or seeing certain patients?
  • Do you feel like you’re not in control, and you’re at the mercy of everyone else’s needs and urgency?
  • Do you suppress your emotions because you don’t have any energy left to deal with your own problems?
  • Are you racing through slap-dash consults with poor notes, OR constantly running late as the day unravels on you?
  • Are you shirking responsibility and leaving your work for others, OR micro-managing and having difficulty handing over the reins?

 If you’re ticking the boxes, you might be burning out.

Interestingly, a Danish study found gender differences in burn-out behaviours for male and female doctors. Men could be completely burnt-out, with serious detachment and cynicism, but still work like an automaton while their personal lives hit rock-bottom. Women on the other hand, would hit emotional exhaustion first, begin to doubt their abilities, feel they weren’t making a difference and lose professional self-esteem.

I’m in General Practice, I left the hospital system because I wasn’t built for that environment and I would most certainly burn out. Plus, I love General Practice – a happy solution for all! But in GP-Land, I deal in people’s daily lives – in the disillusioned, the miserable, and the lonely.  I see the unable-to-copes, the end-of-tethers, and the straw-broken-camels. And when I start to see this in my colleagues, I’m reminded that medicine can be a very, very unhealthy profession, for a combination of factors:

1.    Personality traits: Type-A, Perfectionists and Over-Achievers

You’d probably like your doctor to be all of the above, if you were a patient. But it means they’re a workaholic, who strives to compete and achieve, and is always convinced they’re not quite good enough. Medical schools and specialist training colleges breed competition, one-upmanship and professional insecurity – and bad habits can last a lifetime. Plus, it means they have a REALLY hard time admitting they’re having a really hard time.

2.    Higher Risk and Responsibilities

If the average person makes a mistake at work, the repercussions might be financial – you might lose a sale. If a doctor makes a simple mistake, they might kill someone. Or wreck a life. A contentious doctor has this constantly at back of their mind, every working day. It’s a sobering thought.

3.    Bureaucracy and Limited Resources 

In the public system, there are never enough staff, hours, appointments, beds or programs to provide ‘optimum care’. So there’s a constant pressure on doctors to make judgement calls about how to best utilise limited resources – and arguments from every player involved that their request or demand is the most important. In private practice, this includes the financial and logistic issues involved in running a medical business.

4.    Shift Work and Long Hours

Shift work has been proven to kill you (1,2) and that’s no surprise. But in no other professions are 16-24hr shifts by sleep-deprived workers considered a safe or viable option! They’re inflicted on doctors, because ‘that’s the way things have always been done’, and doctors are considered conscientious and clever enough to ‘withstand’ such unsafe practice. It will probably take many fatal errors with Coroner’s recommendations before the public forces the government to employ more doctors and outlaw unsafe hours.

5.    The Emotional Burden

Doctors and nurses are exposed to trauma, heart-ache, pain, anguish and confronting stories on a daily basis.  We don’t just read about these things – we talk to, counsel and comfort these people.  We have to tell someone they’ve miscarried, or they have cancer. We have to treat angry, grumpy  and manipulative patients to the best of our abilities, despite their behaviour towards us. The emotional toll can be crippling, so you learn to detach.

6.    Learnt Ability to Detach

It’s a survival skill in the caring professions to detach from other people’s suffering, lest you suffer with them. But you can become too good at it – especially if it you start detaching from your own emotions to simply get through the day. Or if you depersonalize patients – allowing cynicism or callousness in your work. Your emotionless detachment can become a habit outside work –  as many a burnt-out doctor’s divorced partner would attest.

So what’s the solution?

  • Demand a culture change in medicine – Gen Y and the growing proportion of female medical graduate (54% at last count), are going to push for a paradigm shift in medicine over the next 10-20 years, one that values a work-life-balance and is kinder to families.
  • Don’t obstruct them, to appease hospital management and budgets, or because you think ‘they should slog it out like I had to.’ Work with them, and advocate for a better, healthier profession for everyone involved. Patients don’t win with burnt-out doctors either.
  • Don’t lose touch with reality – constantly evaluate your work experience against what a ‘normal’ work experience should be, and make changes where you can – would working 4 days a week mean you’re not going to burn out in the long run?
  • Learn your limits – and know when to take time off. There’s no need to race to the finish line in training, and if it takes an extra year but you’re sane, that’s a damn good trade.
  • Don’t heal thyself – seek help if you need it. Have your own good GP, and check in with them if you’re not coping – sometimes just admitting you’re struggling to someone can lift a weight from your shoulders and help you find practical solutions.
  • Watch out for your colleagues, and check-in with them if they’re exhibiting the burnout list symptoms above.

For more excellent advice, see www.thehappyMD.com. And look out for yourselves!