Читать книгу Postmortem - Maria Phalime - Страница 8

My transformation from medical student to doctor was so gradual and subtle that I was hardly aware it was happening. I was completely absorbed in what I was learning and observing, internalising it until it became a part of me. We had come in as innocents with big dreams, and gradually over the years we were moulded into the kinds of doctors who would exemplify the high standards and international acclaim of UCT Medical School and Groote Schuur Hospital.

It was only when I was on the receiving end – as a patient – that I was able to appreciate how far I’d come. I had gone to an orthopaedic surgeon for a minor procedure on my foot. On the day of the surgery he casually rested his hand on my leg as he talked me through what he planned to do. I stared at his hand resting there, how at ease he was touching me as if he knew me. I realised that I did that with patients too – touched their shoulder to reassure them, rubbed their backs when they were in the throes of painful contractions in the maternity unit. I had seen how the senior doctors touched patients, how they connected and questioned, how they probed both physically and verbally. I was becoming one of them.

Our training was rigorous. In addition to the whole-class Friday-­afternoon lectures, we attended tutorials and ward rounds in small groups, and we were assigned patients to examine and present. Our end-of-block exams had both theoretical and practical components; it was the practical exams we feared the most as they brought us face to face with Groote Schuur’s most esteemed clinicians. It was terrifying to stand in front of an examiner and present the clinical findings of the patient you’d seen, and then field questions related to the particular disease. You knew you were doing well when the examiner’s questions became increasingly obscure, even gravitating to the fine print of medicine such as the originators of eponymous clinical signs like Dupuytren’s contracture or Cushing’s triad.

Sometimes this attempt to mould us into world-class doctors was more brutal than it needed to be. Humiliation was an integral part of the way we were taught; it was accepted and indeed expected that at some point during your studies a specialist would grill you in front of your peers – and even patients – in a manner that left you feeling exposed.

As students we were at the bottom of the formidable Groote Schuur hierarchy, with its associated oversized egos, rivalry and one-­upmanship. Some fields were more revered than others, certain specialists more specialised than others. A few of the egos were monumental; one lecturer we simply referred to as God for his inflated sense of importance and infallibility.

The students and junior doctors bore the brunt of the venting of egos. I witnessed one particularly memorable incident at Mowbray Maternity Hospital; I was in my fourth year of study and I was working with a newly qualified intern. We had been on call overnight and during the morning ward round the intern, Samuel, gave a report on the patients we’d seen. He was soft spoken and hesitant, and as we moved from patient to patient I sensed the gynaecologist’s growing irritation. The tipping point came towards the end of the round as Samuel gave a brief account of the clinical findings.

“On examination the cervix was five centimetres dilated,” he said.

The specialist interjected sharply. “If you are going to stick your fingers in a woman’s vagina you better say more than the cervix is five centimetres dilated!”

Samuel stood frozen, and then fumbled as the team of doctors and students waited for him to say more. He hadn’t documented his findings thoroughly, and he was at a loss to give the specialist what she wanted. For the next five minutes we all stood around the patient as the specialist detailed his every omission and dismissed his clinical assessment as shoddy at best.

The specialist was correct in calling him on his oversight, of course. I think many of our teachers were motivated by a desire to produce doctors of a high calibre, who were meticulous in relation to their work. The manner in which they did it, though, sometimes did more harm than good.

I managed to escape the more brutal attacks; there were petty little humiliations along the way, but none that left any lasting impressions.

As exemplary as our training was, I feel it was inadequate when it came to the hands-on procedures. As a doctor you are often required to perform procedures during the course of your work, from simple tasks like putting up a drip to more invasive procedures like putting an intercostal drain into the chest or a central line into a neck vein.

We were never formally assessed on our ability to perform these procedures. The maxim on the wards was simply: See one, do one, teach one. You would shadow a senior doctor, watch them, and then you were deemed fit to perform the procedure yourself. Of course the hope was that the person you were observing knew what they were doing and that by the time your turn came to teach, you would have perfected your technique enough to pass it on to someone else. There were some procedures I never had the chance to learn while at medical school, and only encountered them as a junior doctor in busy wards and casualty units, where the senior doctors seldom had the time to oversee what I was doing.

One of our lecturers, a trauma surgeon, used to say: “Don’t waste time on the dead or dying.” This, like see one, do one, teach one, was one of the dozens of maxims that defined our lives at medical school and the way in which we were trained. We learned to ask intelligent questions and to really listen, even to read between the lines when making our diagnoses. One adage that particularly irked me – not only because it was blatantly sexist but also because it too often proved true – went: A woman is pregnant and lying until proven otherwise. Though crude, this was intended to remind us to always bear pregnancy and its associated complications in mind when dealing with female patients. This served me well on many occasions later in my career.

It certainly came in handy when I saw a young woman during my community service in Khayelitsha. She was seventeen years old but her slight build and fresh-faced prettiness made her look a lot younger. She came in alone and was hesitant as she settled into the chair next to my desk.

“Hello, sisi,” I began. “What can I do for you?”

“I’ve got pain in my stomach, Doctor,” she said.

“How long have you had this pain?” I asked.

“A few weeks,” she responded.

Pregnancy alarm bells went off in my head. “When was your last period?” I asked.

“Some months ago, Doctor,” she said.

“So you’re pregnant, then?”

She shook her head. “No, Doctor.”

I paused. There was a level of sincerity in her eyes that told me she genuinely didn’t think she could be pregnant.

I tried a different approach. “Are you on any form of birth control?”

“No, Doctor.”

“Do you have a boyfriend?”

“No, Doctor.”

“Are you sure?”

“Yes, Doctor,” she said earnestly.

I suspended that particular line of questioning as it wasn’t getting me anywhere and I elected instead to try to uncover other possible causes for her symptoms. I came up with nothing. She had persistent lower-abdominal cramps and she hadn’t had a menstrual period in over three months. Pregnancy seemed the most obvious diagnosis but she was so adamant that she couldn’t be pregnant.

I asked her to lie down on the examination bed in the room. Sure enough, as soon as I placed my hand on her abdomen I felt a mass arising from her pelvis that strongly suggested a gravid uterus, about fourteen weeks’ gestation. The pregnancy was confirmed when I tested her urine.

Sadly, I don’t think this young woman was lying when she told me she couldn’t be pregnant. I suspect she had very little knowledge of how her body worked; she may even have been impregnated by someone who wasn’t her boyfriend, which would explain her strong resistance to the possibility of what I was suggesting.

My training attuned me to the clinical clues that told me what my patients feared to utter. Often I had to read between the lines as some answers lay hidden in the evidence given by symptoms and physical signs. At other times, however, diagnoses were so plainly in view I nearly missed them by searching for more elusive clues. A young man from the Eastern Cape taught me that valuable lesson. He was a patient in the orthopaedics ward at Groote Schuur and was assigned to me during one of our bedside tutorials.

The orthopaedic surgeon instructed me to take a history and examine the patient for later presentation. As I prepared to take a history I was already working through my mind what could have brought a young man to the orthopaedic ward.

I began by asking him what he was doing in hospital, to encourage him to speak openly about his condition. He told me that he had come back from traditional initiation school in the Eastern Cape. He was bright and well spoken, and he’d been briefed not to give the diagnosis away. The sparkle in his eye told me that he enjoyed the momentary wrinkling of my brow as I wondered what on earth his traditional circumcision had to do with his orthopaedic problem.

I tried again. “Bhuti, what happened to bring you into hospital?” I asked.

“I went to the bush for circumcision,” he said again.

I realised I needed to adjust my approach. I thought that perhaps if I heard him out, gave him some room to tell me about his initiation, he would eventually get to the real reason he was in hospital.

“What happened while you were there?”

“I got very sick,” he said.

Initiation schools were notorious – and still are – for their unhygienic practices and the harm that young men come to when there. Every year there are reports in the newspapers of sepsis and even deaths that occur at the more dubious of these schools. If this patient had fallen ill, then it was most likely a septic circumcision wound. But what did that have to do with his bones and joints?

I continued to probe but I gleaned nothing more than his tale of botched circumcision; apart from that he’d been fit and well, and had suffered no other injuries.

I proceeded to examine him, all the time wondering what I was going to tell the surgeon when the time came to present the case. I ran through what I knew of his story, and tried to match it to the physical findings that were emerging. Most of the large joints of his arms and legs had limited movement, and he had a healing scar on his right shin. A picture was beginning to form in my mind, though it remained frustratingly out of focus.

“What happened here?” I asked, pointing to the scar on his shin.

“There was infection in the bone inside,” he said.

In that instant the picture became clear as the pieces of the puzzle slotted into place. His circumcision wound had become infected and the sepsis had entered his bloodstream, where it spread out to his joints and his tibia. When the joints healed the damage had caused them to become fused, which limited their range of motion as I’d found on examination. This young man had suffered a terrible ordeal just as he was embarking on his journey of manhood. Now he was lying virtually immobilised in bed.

As a student I learned a lot from that patient. His assertion right at the beginning of our interaction had held all the clues to what was ailing him; I had been preoccupied with my own ideas of a differential diagnosis, and had been too quick to dismiss what seemed like an irrelevant detail. That young man sensitised me to the importance of listening to my patients’ stories, as they held the clues that would help me in treating them.

Sometimes arriving at a diagnosis was a secondary concern, at least from the patient’s perspective. But as a student I was chasing a diagnosis, an outcome that I could study and analyse. I learned to cut through the fluff, to work quickly in my quest for answers. But in the process I sometimes missed out on the true value of my interaction with patients. This fact was brought home to me during my gynaecology exam at the end of fifth year.

I was allocated an elderly woman with extensive cancer of the cervix. She was from the Eastern Cape and had come to Cape Town to seek treatment for the condition.

I had less than 30 minutes in which to take a clinical history, examine the patient and polish up my notes for presentation to the two examiners. It was a terrifying prospect and I knew that I had to make the most of the available time.

I got straight to the point. “Mama, tell me what the problem is.”

Mama wasn’t working according to my agenda, and understandably so. She was unwell, had received a terrifying diagnosis. She knew nothing about fifth-year exams; I imagine even if she had known she probably wouldn’t care.

“I don’t know,” she responded absently.

Slowly I managed to extract from her that she’d been bleeding heavily, had experienced increasing pelvic pain over a number of months. She kept trying to tell me about her children; she had many and she struggled to remember when each of them was born. I cut her off each time she wandered to them; I needed a clean and succinct reproductive history, not a drawn-out account of her life as a mother.

When I examined her internally I found a large tumour on her cervix, which had spread to the surrounding structures. I also saw the fear in her eyes. Thinking back I realise that in the old lady’s insistence on talking about her children she was trying to tell me about what mattered to her, about the children she’d borne in the womb that was now riddled with disease. All she wanted was to be heard. But I had no time to hear her; what mattered to me was getting to the bottom of her diagnosis.

What I did not realise then was that this would be the trend in the years to come. Over the years I had little time to listen to my patients; to really hear them. I worked in very pressured environments and I was forced to strip away the colour in the stories of patients’ lives to get to the black and white of science and fact.

It is counterproductive to the therapeutic process that so often in our over-subscribed and under-resourced health care facilities the doctor-patient interaction – which is the very epicentre of treatment and care – is such a rushed affair. The therapeutic partnership is reduced to little more than a hurried transaction in which both partners are left wanting. Patients walk away dissatisfied that their complaint was either medicated or dismissed, and the doctor is left feeling that the need for expediency robbed them of the opportunity to truly make a difference in the patients’ lives.

As a trainee doctor I didn’t yet appreciate how keenly I would feel cheated later in my career.

But even in the midst of the rigour, humiliation and tough lessons, our training also had moments of magic.

I wasn’t anticipating anything but cold wretchedness one morning in July 1998 when I heard my alarm clock going off at six o’clock. It was Sunday morning and I could hear the faint pitter-patter of the winter rain against by bedroom window. This was snuggle-deeper­-under-the-duvet weather and I didn’t feel up to the seven o’clock ward round that I was due to attend at the neonatal unit.

I’d anticipated this feeling the night before and had prepared by positioning my alarm clock as far away from my bed as possible so that I would be forced to get up to turn it off. I slowly heaved myself out of bed, begrudging myself my foresight yet knowing that it was futile to resist. I showered and changed, and then ate a minimal breakfast of tea and toast, telling myself that as soon as my duties were done I would come straight back to bed where I belonged.

The five-minute drive to the hospital did little to lift my spirits. The rain had intensified and the wind was driving it horizontally against the windscreen of my car. The deserted streets between my flat in Rosebank and the hospital in Observatory were a mere tracing behind the sheets of rain, and as I turned left into Anzio Road I hankered after the warmth I’d left behind. My clothes were drenched in the short run from the parking lot to the entrance of the Old Main Building, and I cursed the hellish start to the day.

As soon as I stepped into the neonatal unit I was mesmerised. The room was toasty warm and dotted around it were a number of incubators, each housing a tiny newborn baby. There was gospel music playing on the radio, and the nurses hummed softly in harmony as they went about their duties. It felt as if I had stepped onto hallowed ground, and all my yearnings of the morning evaporated.

I joined the neonatologist on the ward round, examining each tiny charge in turn as we went along. They looked barely human; more like newborn puppies with their translucent skin still covered in lanugo, the downy hair that is characteristic of premature babies. They lacked the cherubic chubbiness of full-term babies as they had missed out on the plumping up that normally happens during the final weeks of pregnancy. They looked almost too delicate to handle.

For these premature babies, survival was a very real challenge in their young lives, and their growth and development depended on the specialised care they received in the unit. The incubators were there to keep them warm as their lack of body fat made it very difficult for them to maintain their body temperature. In addition the incubators limited their risk of infection and helped to prevent excessive water loss. They were constantly monitored and each passing day represented an improvement in their overall chances of survival.

Though the neonatal unit was a centre of high-tech medicine, Mother Nature still played an important role. As the babies grew stronger they were transferred to the adjoining Kangaroo Mother Care Centre, where they were carried skin to skin on their mothers’ chests for most of the day. This skin-to-skin contact was as effective as the incubators in keeping the babies warm; in addition, the opportunity that mom and baby got to bond was an invaluable contributor to the baby’s thriving.

By the time I left it was midday, but I could have stayed all day. I had never had such a life-affirming experience in all my medical training.

When I got to sixth year – the final year – I was excited about the prospect of qualifying. I was nervous too. I had seen during my time in the wards that there was so much more that I needed to learn before I was ready to take on the responsibility of patients’ wellbeing. I knew the theory, but I didn’t feel adequately prepared for the hands-on management of patients, the “doing” of being a doctor.

But these were just hurdles, and I assumed that I would navigate them successfully. I was hard-working and resourceful, and I had already overcome so many challenges in my life. I didn’t yet know what direction I wanted my career to take. So many of my colleagues already had their careers mapped out; they knew the quickest route to their chosen specialisation. I was more focused on going into the wards and getting the job done; I figured I would find my fit along the way.

My graduation in December 1999 was a culmination of all those years of diligent effort, the realisation of a dream. I felt proud of what I’d achieved – me, a girl from humble beginnings in Soweto, now a fully fledged doctor. I held my head up high as I walked onto the stage in Jameson Hall to be capped by the vice chancellor of the university.

The real celebration happened a week later back home in Soweto when my mother threw a graduation party. She had provided valuable support throughout my studies, especially during exam time at the end of each year. I always immersed myself so deeply in my work that I struggled to remember what “normal” life felt like. Every­thing came to a standstill then; I studied and subsisted on coffee and sandwiches. My only connection to the world outside of medicine was through her. We spoke often, at least once a week. Those phone calls were my lifeline and they played a pivotal role in keeping me centred.

Talking to my mom brought me swiftly back down to earth, as I realised that not everyone was as absorbed in my exams as I was. She’d usually fill me in on family gossip or the latest goings-on in Soweto. Though publicly she had always been the model of agreeability with never a bad word to say about anyone, she had a sharp sense of humour that few outside her inner circle ever got to see. She piled it on for me, and at the end of our weekly calls I came away wiping tears from my cheeks and nursing aching belly muscles.

For the graduation party we pitched a marquee on the field opposite our home in Pimville and slaughtered animals to give thanks to the ancestors for helping me to realise this dream. As was the custom at such events, friends and family members who had acquired university degrees were requested to don their academic gowns and sashes, and they took the seats of honour and announced their qualifications for all to admire.

The whole neighbourhood was there. For the first time neighbours who had previously treated me as one of the children in the community now addressed me with a kind of reverence that made me both proud and anxious about the responsibility that my qualification had earned me.

In those final days before I began my internship I revelled in my new-found status and enjoyed the praise that was heaped upon me. At the back of my mind, though, I knew that the honeymoon would end. I had seen the harried looks on the faces of interns in the wards; I had heard them talk of their long hours and formidable workloads. Inside a tiny part of me dreaded the day when I would be summoned to the ward to attend to a patient in distress.