A Letter of Apology

This is probably going to be one of the most un-feminist blog I will ever write, but this is one letter that I need to wite.

This is a letter of apology. A letter of apology to my husband.

Dear M,

Every night when I come home from work, I look at your face, and I constantly search for signs of disappointment, resentment and regret in your eyes. I wait for the day when you realise that you have made the wrong decision, or got the raw end of the wife-deal. I count down to the day that you realise you have married a neurotic, anal-retentive female surgeon who is a useless housewife.

Instead, you greet me every evening as if you haven’t seen me for weeks. You hug me as if you have missed me every moment of the day and you kiss me as if it will erase every bad moment I have had during the day.

So I feel that I owe you an apology. Well, several apologies to be exact.

I am sorry for all the last minute cancellations, of romantic dinners, first-time outings, long-awaited concerts, thoughtfully prepared picnics and all other events that we were supposed to have attended.  For the outings we have managed to attend, I am sorry for each and every time we have had to leave early because I have had calls from the hospital.

I am sorry for every date that I have stood you up for, because I got ‘caught up’ at work. I am sorry for when I have kept you waiting, sitting alone at restaurants because I couldn’t just leave an anxious patient ruminating on their fears.

I am just really very sorry that it seems you are not the number one priority in my life.  I give up any enjoyment with you at the drop of a hat because I think someone else needs me more than you,  and they need me more urgently.

I am sorry for all the hours I spend doing paperwork at home when I could be spending it with you. And for bringing them home in the first place because I didn’t have time to attend to them at work – I have been too busy spending time with patient.

I am sorry for the long days and evenings I spend with my colleagues, in clinical work and in meetings; the nights and weekends when I should be having lazy late brunches instead of lecturing, teaching and demonstrating in tutorials for the junior doctors and students; the weekends when I travel to attend conferences instead of walking on the local beach with you.

In fact, I am just plain sorry that I spend more time with my patients, students and colleagues than I do with you.

I am sorry that  when I get home I am so tired that I can’t carry on a decent conversation with you over dinner, or the number of times I have actually fallen asleep in my chair during dinner.  This includes evenings on the sofa when you are telling me about your day and I respond with loud snores. I am sorry for the times when I am not listening to you because I am thinking through an operation, or figuring out diffiult clinical dilemmas in my head. I am sorry for answering my text messages from patients and colleagues while we are talking. And yet, you listen to my constant whinging about my work, hanging on every word and providing advice to help me think clearly.

So I want to say sorry. Sorry that most of the time when I am with you, I don’t give you my 100% undivided attention.

I am sorry that you have not married a Domestic Goddess, that I don’t cook, clean, or pack your lunch for you. I don’t see you off to work every morning with a kiss and a wave in the driveway. I am sorry that you have to do the groceries, drop off the dry cleaning, hang out the laundry and cook me dinners at all hours of the night when I come home from work. Despite all this, I am ashamed that I still begrudge the times you lie on the couch watching sports, stay up all night bingeing on your favourite TV shows and the Saturday nights you spend drinking at the football match with your mates.

I am sorry that I get so busy, I forget our wedding anniversaries and your birthdays.

I am sorry that sometimes I haven’t been able to be with you when you needed me. I am also sorry that sometimes when I get so upset at work, I lash out at you. I am also sorry that I cause you to worry, when I indulge in frustrated tears.

But most of all, I am sorry for each and every day that I forget to thank you for loving me, the way I am.

Diagnosis: I Don’t Give a S#@% about myself

One of the most frustrating things I encounter at work is trying to help people who doesn’t want to help themselves.

Here are the 10 top clinical signs (for the novice):

1. The beautifully tanned patient who is sunburnt all over, (looking like he/she has just spent their weekend on the beach), and is about to go into the operating theatre to have a melanoma excised.

2. An obsession with blenders. The lap band is tight to maximise weight loss, the patient is supposed to be on a portioned healthy vitamised liquid diet. Instead, he lives on a  ‘vitamised diet’ of Big Mac and French Fries, liquified via a blender. ‘I just don’t understand why I am not losing weight…

3. The dangerous oxygen tank. The patient who just had 1/2 of his right lung removed for cancer – so now he is dependent on oxygen – lighting up a cigarette in the hospital courtyard. Taking a drag on their cigarette in between inhaling a whiff of oxygen from their mask. Honestly – if you want to kill yourself, that’s ok, but to blow up the hospital???

4. An X-ray that shows a new fresh hand fracture through plates and screws over an old fracture. Excuse: ‘Well, punching my fridge is better than punch my Dad in the face, rght?’

5. The MIA patient. The patient was called for the operating room, but he couldn’t be found anywhere. Because he was outside for his ‘last smoke’ before having half f his lip removed for  lip cancer. ‘You only told me that I couldn’t eat or drink before my anaesthetic, you didn’t say I couldn’t smoke.’

6. Patients with bags of ‘unfilled’ medication scripts. One is really unsure as whether these patient don’t take their prescribed medications (for their heart disease, cholesterol, diabetes, infections etc), because they can’t be bothered, they don’t want to or they just ‘don’t believe in taking medications.’

7. DNA’s (did not attend). Patients who have appointments for their cancers to be assessed and removed do not turn up to their appointments despite multiple phone calls, or simply, they have important work-commitments or holidays and need to move their appointment to 6 months later when things are quiet (and the cancer will be inoperable.)

8. The broken plaster on a broken arm. Sometimes, the non-existent plaster on a broken arm. ‘I know my arm is broken, but it got so itchy I had to take the plaster off’.

9. The gigantic fungating cancers. It takes time for cancers to grow. When I see a very very large cancer, I wonder why patients don’t come in when it was the size of a coin. Once I had a patient with a skin cancer on his chest. It was the size of a dinner plate, and it had already eaten into his breast bone. I asked him why he left it until now to come, he said that he only came in because it was growing into his neck and he couldn’t hide it behind his business shirt and tie at work anymore. Did he know it was a cancer? Yes, but he was too busy at work to take time off for an operation.

10. The smoker with a cigarette dangling out of his neck. The throat cancer patient who had his throat removed now has to breathe out of his tracheostomy. He was found lighting up with a cigarette taped to his tracheostomy. A short-cut highway of delivering poisons directly into his lungs. Well, I guess he won’t get oral cancers from smoking this way.

The Differential Diagnoses:
1. I have a severe case of NFI (No F&%$* Idea)
2. I am so f$%#@ scared that I’d rather bury my head in the sand
3. My health is my doctor’s responsibility because that’s their job to fix it

But sometimes we just have to face the harsh diagnosis of: I don’t Give a Shit about Myself.

 

Things you shouldn’t say to your surgeon before your operation

I have had a very long tough day of operating, so please allow me some self-indulgence in writing this blog. I sincerely apologise in advance for the sarcasm and disillusioned humour to follow!

The last thing anyone wants is an annoyed surgeon operating on them. I mean, would you be obnoxious to your chef or the waiter that is serving you? (We all know they will spit in your food) Would you be an ass to your dentist just before he/she picks up the dental drill? So why, oh why, would someone piss their surgeon off just before being wheeled into the operating room?

‘I have been waiting for 2 hours since 8 o’clock.’

My answer: ‘Oh, that’s great, you arrived nice and early so you are now all ready to go in.’

What I really want to say: ‘Sorry, I just finished my 2-hour champagne breakfast, hic.’ or ‘Are you in a rush to go somewhere after your operation?’ or ‘I’d better go faster during your operation then, so you can get home sooner.’

‘Are you sure you have done this before?’

My answer: ‘More times than I can count, you will be ok.’

What I really want to say: ‘No, but there’s always a first.’ or ‘No, but I watched it on You-Tube last night, and I think I got the general idea.’ or ‘Yes, when I was a medical student, on a pig in the lab.’

‘How come this operation costs so much?’

My answer: ‘Because it is a major operation, it takes a lot of time and expertise to do.’

What I really want to say: ‘Because you have come to a surgeon, not the local butcher.’ or ‘You are free to shop around, maybe it will be cheaper if you get it done over the internet.’ or ‘I don’t do surgery because I love helping people, I do it for the money.’

‘Would I have a scar? Will it be ugly?’

My answer: ‘Yes, you will have a scar, just as we discussed before. It will fade.’

What I really want to say: ‘Of course you will have a scar, moron, you are going to be cut open and I may be good, but I can’t perform miracles.’ or ‘No, you won’t have a scar, because I do it all by telepathy.’ or ‘Yes and Yes.’

‘Please do a good job and don’t kill me.’

My answer: ‘Don’t worry, we will do our best to look after you.’

What I really want to say: ‘Ok, for once I won’t make a mess of it, but have you signed a will yet? You know, just in case.’ or ‘Do I get a bonus if you get to live through this?’ or ‘You are expecting too much from me, I don’t think I can handle it.’

‘If the operation doesn’t turn out to be what I wanted, can I get a refund?’

My answer: ‘No, but if that’s the case, I will do my best to give you a result you are after.’

What I really want to say: ‘Sure, if you want a refund, we will have to put the cancer back too.’ or ‘No, because I can’t take the implants out of your boobs when you’ve changed your mind and use it for someone else.’ or ‘No, because I have never learnt how to undo a facelift.’

‘Have you been working all day? Are you too tired to do my operation? Can you please pay attention when you are doing it?’

My answer: ‘This is a normal working day for me, I am fine and you will be fine too.’

What I really want to say: ‘I will be fine. My hands will be steadier once I have had a drink.’ or ‘Don’t worry, watching the tennis on my laptop during your operation will keep me awake.’ or ‘I am fine, my ADHD is under control, I have just had my 6 oclock dexamphetamine.’

‘Do I really need to have this operation?’

My answer: ‘Remember what we talked about before? I would not be recommending an operation unless you need it. You will be ok.’

What I really want to say: ‘Did you hear anything I said last week during your consultation?!?!’ or ‘No, you don’t need this operation, I just like cutting people open for fun.’ or ‘Yes, you really need this operation because I really need to save up for my Ferrrari.’

‘You look too young to be doing this, do you know what you are doing?’

My answer: ‘Oh, that’s so sweet, thank you. I am actually older than I look. I have done this for several years now, so I think both you and I will be ok.’

What I really want to say: ‘If you prefer to go to Old Shakey next door, you are welcome to swap surgeons.’ or ‘I have done heaps of this operation on cadavers during medical school. I graduated with honours last week.’ or ‘I only look young because you are so old.’

 

Ok. That last one was bad. I should stop here. I should go to bed, get some sleep.

Because come tomorrow morning, I have to find my professionalism, tolerance and patience. Again.

Teaching by humiliation

This is not a blog about bullying. Just about teaching.

Last week, I witnessed a scene in an operating theatre.

Two doctors were operating on a patient. One was the senior consultant and the other, the junior resident. The tension in the room was palpable, and even the humming of the ventilator sounded like a jumbo jet. The operation was not going well. There was constant welling of blood in the body cavity they were concentrating on, and the sucker tubing gurgled continuously with bright red fluid. Stress was evident as expletives started to escape from behind the older doctor’s mask., directed at the younger man.  The junior resident was trying his best to help, but he was obviously straining under the other man’s diatribe, apparent in his worsening tremor and the inability to stop the blood from flooding the operating field.

Then, miraculously, the senior surgeon managed to control the situation, and it was as if everyone in the room released their long-held breath in unison. The older surgeon gave an arrogant laugh, ‘It would really ruin my numbers if that one got out of control.’ He daftly tied the loops around the bleeding arterial branch. The operation continued, but as it progressed, it was clear that the resident was starting to annoying the older surgeon with his scrutinised clumsiness. At times when the younger man got in the way, his hands were swatted away like a bothersome fly, accompanied by over-dramatic exasperated sighs from the senior surgeon.  When the resident missed a suture with his scissor, it was snatched out of his hand with an expletive, as the older man made a deliberate show of cutting his own sutures, to demontrate the younger doctor’s incompetence.

The tremor in the young man’s hands deterioated. By the time it came for him to close the wound, one could almost hear the instruments vibrating against the patient’s skin. Criticisms started with a few grunts, escalating into abrupt barks of ‘Don’t’ and ‘Stop’. Finally, the needleholder was grabbed from his hand roughly by the senior surgeon. The older man started to close the wound himself in angry jerky movements, at the same time, a barrage of insults descended on the young doctor.

‘Pathetic aplitude for surgery….’

‘You will never make a surgeon…..’

‘What were you thinking taking on this job…..’

‘I don’t know how you could have made it this far as a doctor…….’

‘you are useless…. It wouldn’t have taken me this long if it wasn’t for you……’

‘Why is it that I always get the most pitiable incompetent junior doctors….. ‘

It was as if the avalanche was unstoppable, hammering down at the young man whose head was bowed over his scissors, staring at the wound in concentration as if it was his lifeline. As the last stitch was cut, the older man threw down his instruments on the table and tore his mask off.

‘Put the dressing on and get out of my operating room, before you sabotage anymore of my operations, you worthless excuse.’ He marched out angrily.

The room was quiet. No one said a thing in the last two hours. Including myself. Why? You may ask. Because we were all too afraid, that if the attention was drawn away from the junior doctor, the torrent of abuse would only continue, just at a different target. We knew this from experience. Dr M* was well-known for his vicious disposition. Anger management classes and suspensions did not apply to him, as everyone knew that he was about to become the next Director of Surgical Services. Over the last few years, complaints about him mysteriously got lost, and disgruntled staff members seemed subdued when questioned.

But, it wasn’t the unfairness, or the endless onslaught of malice that shocked me, but the silent tears that were now running into the mask of my younger colleague as he carefully applied the bandages on the wound.

In front of me, was a grown man, reduced to tears.

I knew Peter* well. He was an eager young medical student when I was a first year training resident in surgery. It was an interesting time, with me trying to find my feet as a newbie in surgery while he took everything I did as gospel. Peter was like a curious sponge, everything I taught him, he investigated and researched until he fully understood all there was to know behind each surgical fact.

But that was more than 10 years ago. The man in front of us now was a final year trainee, about to step into the world as a fully qualified surgeon within 3 months. He was a husband to a fellow doctor and a father to 8 year-old twins. What would the children think, if they ever saw their father, standing with his shoulder slumped, his hands shaking, and tears pooling in his mask? It broke my heart. This was a grown man, broken, momentarily, by the maliciousness of another.

Awkardly, I walked over to him. I took the bandages from his limp hands, and I rested my hand on his back.

‘Three months, Peter. Three months. Just hang in there.’

He stared at the floor.

I gave him a gentle shove. ‘Go and write up your operation notes. Grab a coffee. You have another case to go.’

He seemed to gather himself. He took his mask off and swiped at his eyes. He nodded, then looked up. Like all surgical trainees – hard veterans of regular abuse – he reached deep inside himself, found his ultra-thick ‘surgical hide’, and threw it over himself in a protective shroud. Like a magical cape, the despair was suddently erased from Peter’s eyes as if the last 3 hours did not exist. Red rims and puffy eyelids were the only evidence that something may have been amiss. A lop-sided smile broke through. ‘I need something stronger than coffee.’ A self-depreciating laugh followed as he strolled out of the room, looking for all as if he had just accomplished a simple case without a hitch.

It is true that bullying is rife in the field of surgery. It may sound as if I am making excuses, but the stress and pressure can often result in unintended explosions of emotion – which majority of the time, is usually let lose at the most junior person in the room – and never in a positive way. The inferno is often directed at the person least powerful to fight back – which is our trainees or students. They are dependent on their senior surgeons for their assessments and recommendations. Not to mention references for future positions. Surgery is a small world, and a close one.  Reputations have a way of establishing itself as early as one’s training years.

It is such a cliché when I say that it was the way I was ‘brought up’ in the world of surgery, and I honestly believe, it made me tougher. A surgeon need to be able to withstand unforeseen stresses, make snap decisions in dire situations and be able to get on with the next operation even when the previous one has failed. I remember being completely accepting of the fact that when I signed up for surgical training, I was going to get abused, yelled at, bullied, hassled and most likely reduced to tears at the most inconvenient times. I remember the incredulous looks from my non-surgical colleagues when I said (tongue-in-cheek), ‘but there is no such thing as bullying in surgery. It is called teaching.’

I remembere being pulled aside by my mentor in my early years, who tried to warn me about a particular senior surgeon’s bad temper, and his love for torturing trainees with spiteful intimidation. I just shrugged, to her amazement, I was not concerned, ‘Well, the way I see it, is that he doesn’t have to teach me at all, but if he is willing to teach me, even if it’s by humiliation, I am willing to learn.’

Sure. I know I am tough. But I had to be. When I was training in surgery, I was one of the very few females in my specialty. I was determined not to give anyone an excuse to call me a girl – because I was a grown woman, and I was gong to be as good as any grown man around me. Some were harsher with me because they thought I belonged in the kitchen, some were easier on me because they were susceptible to a pretty smile, heels and pencil skirts. Constructive criticisms were given, some verging on bullying, whilst others just needed to be accepted with a stiff upper lip.

Now, don’t get me wrong. I don’t think it is right to teach by abuse, but everyone knows how hard it is for an abused child not to repeat the same life-cycle as his/her parent. I cringe everytime I hear myself say, ‘back in my days…..’

Because back in my days, if a trainee has not looked up an operation the night before the operating list, he would have been sent to the library for the remainder of the list until he knew how to recite the all the procedures back to front. Then, maybe, he may be allowed to hold a scissors and cut the sutures for the senior surgeon.

Despite the long-history of the harsh realities in surgical training, generation change has definitely brought new approaches to teaching. A trainee is like a trade apprentice. Except teaching only knowledge and skill is not enough. The importance of cultivating empathy, integrity, responsbility and collegiality all need to be incorported into the rearing of a good surgeon. And if we start with abusing them, none of these quality will get an opportunity to flourish. Not if their everyday aim was to survive the day without being reduced to tears, or feeling as small as an ant that is just about to be crushed under a surgical boot.

I remember vividly the first advice ever given to me.

You will become a good surgeon if you are a good person, but you aren’t necessarily a good person just because you are a good surgeon. When surgery fails, your integrity is the only thing that will lead you to make the right decisions.

Peter is a good man. He will one day make a great surgeon.

*All names have been changed to ensure confidentiality and protect personal identities.

Smoked Salmon

It was after a very long day at work.  A complex operation that took me ten hours, standing on my feet, without a break.

I was so tired I was almost asleep by the time my car rolled to a stop in the garage.

Dinner was served to me at the table, lamb racks, fresh boccoccini, tomato and basil salad. My husband and I ate silently. I was too tired to evening lift the fork to my mouth, let alone make any intellectual conversation.

‘Is dinner ok?’ He looked at me in concern.

‘Yeah.’ was my half-hearted reply, pushing a piece of cheese around.

‘Don’t you like the salad?’ he asked, almost defensively. ‘I thought you like it, that’s why I made it.’

‘No, no, I like it.’ I said, too tired to argue. Which obviously came out pretty unconvincingly.  In actual fact, I did, and I do. It is one of the salads he makes which I love. I was just too tired.

He looked at me suspiciously.  ‘Are you just saying that or do you actual like it?

A pause, then he asked in a slow, deliberate tone, ‘Is it a smoked salmon?’

Ever since the ‘smoked salmon incident’, I have lost my husband’s trust in my ability to tell him the truth of what I like and what I don’t like.

It happened two years ago. At the time, he was working in the UK, and I was visiting him. He was working night shifts, and because he needed to take the car to work and was living quite far out of town, he made sure there was plenty of food in the fridge for me before he left for work each evening. A week down the track, he was cleaning out the fridge and noticed there were packets of smoked salmon sitting on the top shelf in the fridge.

‘Why aren’t you eating the smoked salmon? They are nearly out of date.’ he asked me. ‘I bought them for you.’

I walked over to the fridge door and looked at him in confusion, ‘but I don’t like smoked salmon.’

He looked me incredulously in return. ‘Are you telling me,’ he said in a dangerously quiet tone, ‘that after 18 years, I am just finding out that you don’t actually like smoked salmon?’ A deep breath. I could almost see the pressure increasing behind those grey eyes. ‘Why haven’t you told me before? Whenever we are at the supermarket, you just let me buy packets of salmon!’

‘Because I thought you liked it.’ And I did.

‘So what did you do with all the packets of smoked salmon we used to buy?’

‘I had to keep throwing them out because they were out of date. I was wondering why you kept buying them and not eating them.’

‘Because I was buying them for you. I thought you liked them.’ By now, I was sure the neighbours in the next apartment has their heads under their pillows.

And so there it is. Smoked Salmon. I had to tell him, after 18 years of being soul-mates, that….. I. Don’t. Like. Smoked Salmon.

The truth is. I don’t hate smoked salmon. I will eat it if Í have to, or if there’s nothing else to eat. But I don’t deliberately go look for it, or seek it out. If there was a choice on the menu, it will not be my choice.

It took me a while to realise why I have never bothered to tell him I don’t like it. It was simply because I thought he liked it. And similar to most couples (who, like us, have obviously been together for too long), I sometimes end up doing things or making decisions to please him, because what makes him happy, makes me happy, and most of the time, it wasn’t worth the effort to debate about it.

Unless it’s something I really hate. Like Golf. I drew the line at Golf. He was on his own for that one.

So when he refers to a ‘smoked salmon’, he is basically referring to his lack of trust in me to tell him the truth about my preferences. He is now constantly suspicius that I do things or make decisions to placate him. I am working on regaining that trust – which I did have for the last 18 years until that sudden moment of enlightment at the fridge door.

But most importantly, for me, a ‘smoked salmon’ is a reminder that I need to be truthful to myself, and trust that even if I don’t like what he likes, he still loves me.

Two minutes

Mrs Warren* came into my practice yesterday.

Mrs Warren is the mother of Hannah*. Hannah was a 35 year old beautiful young mother of three children, who passed away from metastatic breast cancer two weeks ago. Hannah was my patient three months before she succumbed to her illness.

I heard Mrs Warren’s voice at the front desk reception.

I stayed in my office, consumed by guilt. When Hannah was dying in hospital two weeks ago, one of the nursing staff informed me about her readmission into hospital. ‘Things are not good, I don’t think it will be long.’ 

‘Maybe I should pop by and visit.’ I thought, mentally swiping at the tears that threatened to clog up behind my eyes.

‘I think they will really like that. Hannah loved you. She thought the world of you.’

I started, then realised I had thought out aloud, the nurse was just responding to my comment.

Days, then weeks passed. I couldn’t bring myself to visit her. Several times I walked towards her room – steeling myself to walk in to face her emaciated semi-conscious form on the bed, surrounded by her grieving family – then finding myself turning, striding rapidly away.

Hannah was my age. She was a lawyer, a lawyer who studied hard, worked long hours, made sacrifices and achieved. She once told me that she was the youngest associate ever to be offered partner. She told me how there was no female lawyers in her department at which we both smiled simultaneously in mutual understanding. She said she sees a reflection of herself when she looks at me. As I do, when I see her.  

I never went to see her, I never said goodbye. I never attended the funeral. AFter all, I told myself, she wasn’t a friend. She was a patient. The only thing I did, was to write a card to her family.

Now her mother is standing in my office. And I am kicking myself. I should have made more of an effort. It would have just been ten minutes of my life; After all, my ten minutes would have been nothing compared to ten minutes in her last days. My cowardice overwhelmed me,  I found myself hiding in my office, afraid to move. Or breathe.

‘Hello Mrs Warren, we are so sorry to hear about Hannah.’

‘Thank you.’ I imagined her waving her hand elegantly. Mrs Warren always reminded me of a grand matriach, she moved and spoke with such pride and grace. ‘I just wanted to come in and thank the doctor for her card.’ A sniffle. ‘It was so lovely that I had to read it to Hannah yesterday.’ A brief silence was followed by a sharp snap of a handbag. Must have been a tissue. I could almost see her in my mind, using the task as an oportunity to gather her composure.

‘You know, we had so many people at the funeral last week, the church had to leave the doors open.’ There was less wobble in her voice. ‘We got so many flowers and cards.’

‘She had so many specialists, but doctor was the only one who sent a card. Please thank her for me, we were so pleasantly suprised……’

I shut the door.

Tears were running down my face. I was humbled.

It seems the two minutes it took for me to write a card was enough for them.

 

 *All names have been changed to ensure confidentiality and protect privacy.