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The Ugly Side Of Becoming A Surgeon

Discussion in 'General Surgery' started by Mahmoud Abudeif, Jul 6, 2019.

  1. Mahmoud Abudeif

    Mahmoud Abudeif Silver Member

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    I never thought I would say this, but I broke. I give up. I am done. I surrender. I am handing back my dream of becoming a surgeon. I have nothing left to give. I don’t want it anymore. I’ve lost my ambition. I’ve lost my spark.

    I started 2018 with optimism and zest. This year would be my year. I would apply for the advanced training program for Plastic & Reconstructive surgery. I’ve done the hard yards, I’m good at what I do, and I have the right intentions… Fast forward to October and I find myself in a hospital bed, barely able to speak or move. If I wasn’t so resilient, maybe I wouldn’t have put up with the abuse for as long as I did. But I did. And all I can do now is focus on what I can do now to get myself back to my former, bouncy self.

    Purpose

    What is my purpose in writing about my demise? Won’t it just remind me of a painful time? That is true, but I have several purposes for writing about it. Writing is therapeutic. I’ve always been into journalling, to chronicle my every day life. I also believe that writing down my whole story is going to be an important part of my healing. By sharing my story I also hope to raise awareness about doctors’ health, work-life balance, safe working hours, and the toxic surgical environment that still exists in Australia.

    It’s not all going to be a danse macabre. This post will merely set the scene for my lowest point in my life thus far, and I will be blogging later about how I’ve been able to waltz out of my ashes, which is still a work in progress but I’m getting there. This is by no means a post about trashing any particular person nor do I want to discourage anyone from pursuing their dreams of becoming a surgeon. However, I do lament “the system” and I do wish that I knew some of the things I know now before I decided to pursue this path.

    I hope that by reading this, some of my junior colleagues will get a feel for what it’s really like so that there are no false illusions about what it takes to succeed in certain sub-specialties. Maybe it might even help bring about a change in surgical culture.

    Bright-eyed and bushy-tailed beginnings

    It was 2007. I walked into an operating theatre for the first time. I felt an instant buzz. This is what I want to do. I’m good with my hands. I am meticulous and focussed on perfecting my technique in everything that I do. I had performed well in the Anatomy exams, which put me in the top 3 (out of 250 medical students) in my grade. I was invited to teach Anatomy at my university the following year, for which I was recognised by the Vice Chancellor.

    My love for surgery grew further in my final two years of medical school. I was nicknamed “Christina Yang”, after the surgery-obsessed Grey’s Anatomy character, and yes it’s convenient that I happen to also be an Asian female. I was always the first to arrive at the hospital, and the last to leave. “Your suturing is better than the resident’s,” a voice whispered in my ear. I smiled underneath my mask. I would follow the surgical registrars around, making myself as useful as possible, and took every opportunity available to improve my skills.

    I loved my internship and residency terms. My ambition did not waver. I stayed back after hours to assist surgeries – not because I had to, but because I wanted to spend more time in the operating theatre. After each surgical rotation, the consultant supervising me would give me full marks and say “you’re the best intern/resident we’ve had”. Nothing could hide my smile that beamed from ear to ear. I took all the pre-requisite courses. I sat my surgical primary exams early. I still maintained a healthy social life and I had taken up long distance running. Even during busy terms, I would still make time to go running a few times a week, and I made sure I did at least one charity event a year. I was loving life.

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    I received the same Wonder Woman birthday card two years in a row from two independent friends who don’t know each other. I never thought of myself as anything special but I loved the idea of becoming a superwoman.
    Dream Disintegration

    It was 2013. I started to see the dark side of surgery. One of my registrars had been reprimanded by a neurosurgeon. He stomped on her foot and broke it. What?! I was working hard on the Neurosurgery ward but I was denied access to the operating theatres in favour of a pretty girl. Let’s call her Sally. Tall, skinny Sally had perfect curls and beautiful green eyes. I had been on the team from the beginning of term, but Sally was just working as a reliever on our team for a week. My ears would prick up every time the senior registrar would mention needing an assistant in the operating theatre. “We’ll take Sally,” he said, with a dirty smirk on his face.

    I didn’t see the inside of an operating theatre that term. A huge contrast from the year before when I was the only resident chosen to teach at the junior doctors’ Neurosurgery workshop alongside the registrars. One surgeon decided that whilst I may have been the “best resident” last year, this year I was “on a downward spiral”. He didn’t have an explanation for it. “Take your clothes off,” he’d taunt me in Japanese so that no one else would know what he’d said. And then he laughed. I was relieved to hear that that very surgeon had been asked to resign in 2015.

    The registrar years

    I loved Melbourne, but work brought me back to Sydney for my registrar years. I love(d) being a registrar. I’ve always been a leader, not a follower. I liked being in charge of the daily running of my unit, and with Japanese efficiency I would plan the day out for my team and delegate the tasks. I’d always make time for a team coffee to take the medical students and junior doctors for an impromptu teaching or mentoring session. Word spreads quickly when there’s an enthusiastic teacher, and I ended up giving education sessions to the extended care paramedics too. The more the merrier. I was passionate about my specialty, especially hand surgery, and I was keen to share the love.

    I kept a good routine whilst I was a registrar. I’ve always been a morning person. I’d wake up around 4:30am, exercise for an hour, eat a proper cooked breakfast and brought a healthy packed lunch for work. If I still had energy at the end of the day, sometimes I’d even exercise after work, too. I kept up my enthusiasm for endurance events and signed up for at least one half marathon a year. I enjoyed work, I liked the people I worked with, and I would bake cookies or cupcakes every week to bring to the weekly unit meeting. I embodied exactly the kind of registrar I wanted to be when I was younger.

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    Sitting in the operating theatre tea room writing up some notes
    The worst working days of my life

    February 2018. The start of my term at Hospital X. I had just finished a term where there were three registrars who shared the on call responsibilities equally. Hospital X was staffed by two, so I knew I would be busier… but it wasn’t a 50/50 split. It was 10/4 (me being the person on call 10 days a fortnight).

    My two-week cycle looked something like this: I was on call from Monday morning 7:30am until the next Monday 4pm… about 180 continuous hours. This means that at any time during those 180 hours, I could (and did) get called by the hospital. From the first week I was receiving phone calls every night until about midnight, and sometimes even a 3am call here and there. I would then get Monday night off – a momentary relief of one night’s uninterrupted sleep – and then back on call again the next morning until Friday afternoon – another 80 continuous hours of being on call. I got 2 days off, and then the cycle started again.

    My days were long. I kept a log of my hours; I was at the hospital for 120-140 hours a fortnight, and work would follow me home with phone calls whilst trying to park my car in the garage, whilst I took a shower, whilst I was trying to cook dinner, and whilst I was trying to fall asleep. Every fortnight I would only be guaranteed 4 nights of uninterrupted sleep. The other 10 nights were unpredictable. Maybe I’ll get woken up, maybe I won’t. This mental unrest for 10 days a fortnight was taking a toll on me. I couldn’t go and exercise, I couldn’t plan anything social… I had to be on standby.

    Oh, and I was also made to cover some of the on call roster for the Ear, Nose and Throat (ENT) surgery department – a specialty I had no prior experience in. The ENT registrar was not required to reciprocate. I wasn’t treated too kindly by the ENT department, because I wasn’t one of their own. I had admitted a little boy who had a lot of pain after he’d had his tonsils removed and he couldn’t eat. I called the surgeon who did his operation, but before I could finish my sentence, his response was; “He’s not a private patient. I’m not on call,” and hung up. Care factor: zero.

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    My second bedroom
    At the end of my first month at Hospital X, I had done more than 100 hours of overtime work. I participated in a charity ride a few weeks later to raise money for the Children’s Hospital Burns Unit, and I fell off my bike after riding 100km. My brain was wrecked and I had lost concentration for a moment. I was already embarrassed about how slow I was, let alone falling off my bike.

    I handed my time sheet to Medical Administration and raised my concerns about how much work I was doing, and how exhausted I felt. The response was, “I have nothing to do with the roster, you have to talk to your own department”. I was worried about how tired my brain was… I need to be fresh to make clinical decisions. I didn’t want to make any mistakes. There was a patient who came back with an infection after surgery. The antibiotics she was supposed to have been charted were not. I wrongly got blamed for that complication.

    I was spending more and more time at the hospital. Breakfast was a coffee and banana bread at the hospital cafe. And lunch was an equally unhealthy meal at the cafe. It’s ironic that a hospital cafe can’t provide healthy options. I was eating hot chips every day. I was craving sweet and fatty foods for that quick energy boost to keep me going. I knew I was gaining weight, but I didn’t have a choice. Dinner was often Uber eats. Some nights I would finish too late to drive home (which was an hour away), so I would find a spare bed on the Recovery Ward. “Recovery”. How ironic. I went to sleep to the beeping of machines, pagers, and the voices of staff working the night shift. It was hardly a space to recover.

    After a while, the other doctors began to notice how much time I was spending at the hospital. My locker had spare clothes, socks and toiletries in anticipation for all the nights I would be spending at the hospital. By April I began to feel physically unwell. The combination of stress, dehydration, poor nutrition, and sleep deprivation affected my gut health. (I will be writing a follow up post on the effects of chronic stress on the body.)

    The head of department (HoD) had heard some whisperings about my fatigue and gave me a call that weekend. “We need to look after you. You’re damn good, you’re damn good,” said the voice on the other line with so much conviction that I believed it. “I don’t want you to burnout” … but I already was. For a moment I thought that maybe this roster might change.

    Then, I experienced the worst week to date. It started with a 12-hour day on the Monday, as I had a presentation after work that finished at 7:30pm. Tuesday was 20 hours long. I had just finished operating on a little boy who had cut off the tip of his finger, which required re-attaching urgently to save it. It was 10:30pm at the time and I was getting changed to go home when I received another call from the Emergency Department. Since I was still in the hospital I decided I would go and review the patient on my way out.

    The man had cut three of his fingers with a kitchen knife after grabbing it and planting it tip-down so that it’d stand up on the chopping board. One of his fingers looked pale so I was concerned about the blood supply to it. I knew I had to take him to the operating theatre that night. I called my boss for help, but he didn’t come. “You’re good at micro, you’ll be fine, see you in the morning,” he said. The patient was a manual labourer and that was his dominant hand – no pressure at all.

    I went back up to the operating theatre, changed back into scrubs, and informed the staff there that I had an urgent case to do. I was exhausted but drank some tea to wake myself up. The anaesthetist felt sorry for me and shared a bit of his dinner with me. My eyes were sore as they looked down the microscope to assess the fine structures in this man’s hand. It took four hours to repair all of the tendons, nerves and arteries he’d damaged across the three fingers. Hello Recovery Ward. Let’s sleep here again for a few hours.

    “Was I dreaming, or did you call me last night about a case?” asked the surgeon. “I did ring. I finished operating at 3am,” I told him. “You’re a legend,” he said, patting me on the back. I half-smiled. The HoD was also there that day and I asked for permission to take a quick break. The answer was no. “I remember doing those sort of hours when I was at your stage. It’s good for you”

    Was this supposed to mean that this experience would toughen me up? As a marathon runner, I think I might know a thing or two about pushing my physical limits. Mind over matter. I was made to feel as though I needed more mental tenacity. My tiredness had nothing to do with the illegal and untenable hours I was working. Of course not.

    It was Wednesday and that day was 16 hours long, and I did not get that break I desperately wanted. I was so tired that I slept over at the hospital again. Days like these continued well into April. At this stage, I realised that nothing was going to change and my department was benefiting from the fact that I could operate on my own, and they could (literally) leave the unit in my hands.

    The days were made unpleasant by all sorts of factors. Being a female never helps, no matter how competent you are. Even after introducing myself as the treating doctor and performing an assessment on a patient, I’d still get asked, “Nurse, when do I get to see the doctor?”

    It wasn’t just the patients. An Emergency doctor rang me at 3am about an appointment. At 3am? Really? I expressed that it was inappropriate to wake me up at 3am about non-urgent matters. This was hardly an emergency. “Stop being an emotional female,” he said. Oh no he didn’t…. Would he have called my male counterpart “emotional”? I tried to get back to sleep but I couldn’t. How dare he call me emotional!

    And yet, when an Emergency Department consultant asked me to run a workshop for their doctors, I agreed. I gave a tutorial on how to assess hand injuries and a practical workshop on how to make a good plaster for broken hands. Even after that experience, my passion for education was still there. Just. I didn’t have time to brush my hair or make a home made meal, but I made time to teach other doctors.

    I also had to cope with a high level of violence and aggression at Hospital X. The operating theatres were always inefficient and I would spend almost every day apologising to patients that their surgery was cancelled for the next day and that they would have to come back. I was on the receiving end of a lot of abuse from family members who were angry that their loved one had been fasting all day only to have the surgery cancelled at 10pm. It was so demoralising to apologise for something that was out of my control, but it was all part of my role.

    In mid-April, I went to see my family GP about my gut problems. She weighed me, and for the first time in my life my BMI was in the overweight range. I’m supposed to be a runner. How can I be overweight? She’d known me for several years now, and was concerned by how physically and mentally exhausted I appeared. She felt strongly that she needed to write a letter to the hospital, which I gave to my HoD and medical administration.

    The letter from my GP made no impact, but I knew I needed to ask for some time off. I also had a sick family member who was about to start chemotherapy, and I felt guilty that I wasn’t there to support my family (especially being the only medical person in the family). My family sent me blood test results and images of scans to keep me in the loop, but it only served to amplify my guilt. The hospital knew of this but I received no sympathy, which you’d normally expect if an employee’s loved one had incurable cancer. It makes me sad that doctors work so hard to look after patients, yet (some) hospitals provide no support to doctors during times of need.

    I came back from annual leave with the hope that my working conditions might improve. There were no such improvements; only an extra load imposed on me for taking time off – I didn’t realise that taking annual leave was a punishable offence. I was given an extra weekend to “make up” for it. The only thing that kept me going was a new patient, whom I shall call Mr B. He was a polite and softly spoken gentleman who had developed a nasty finger infection. I was able to treat most of his infection surgically, but he needed further management with intravenous antibiotics and regular dressings.

    I wanted the dressings to be done in a particular way, and since my department was not given any nursing support in Outpatients, I would be the one doing it. Mornings suited Mr B and his wife, so I booked him in every morning for 8am and that became my social life and reason for getting up every morning. As well as no nurses, we also didn’t have a hand therapist (despite offering hand surgery), so I was his doctor, nurse, and physiotherapist.

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    A hospital that offers hand surgery should probably have a hand therapy service to provide the necessary post-operative splints and exercises… but that’s none of my business.
    I saw Mr B and his lovely wife every morning. Before walking into the Outpatients department, I took a deep breath, put on my brightest smile and greeted them Good Morning. His blood test results and the appearance of his finger was improving day by day, and I reassured him of that. “You’re my guardian angel,” he said… but actually, he was mine. Without the pleasant daily interaction with Mr B and his wife to look forward to, I’m not sure what else would have motivated me to get up for work every morning.

    By this time it was May. I grew more and more weary and disillusioned. I had been trying so hard not to complain because I knew what was at stake. I needed to get onto the advanced training program. It was like I had put my whole life on hold and I was not a valid human until I got accepted onto this program. I needed my bosses to support my application, which meant I would have to keep working tirelessly and produce perfect surgical results.

    I couldn’t keep my eyes open, but I could keep my mouth shut. During the day, if I had a spare moment I would go to the registrars’ office, cover my face with my jacket and sleep on a chair. “Who’s that?” I would hear a voice say. “Oh, that’s the Plastics Reg, she’s always here,” would reply another. I stopped caring that I was looked upon with so much pity. I was nothing like the Wonder Woman card my friends had given me. I didn’t even know who or what I was anymore.

    Hospital X was a small hospital. The Head of all of the surgical departments had gotten involved by this point. “You can’t make her do all of this on call. The roster must be changed”. Those were his orders, but ultimately it was up to my department. I had already expressed a concern that my ability to care for patients had become compromised because of my extreme exhaustion. It was beyond burnout.

    I didn’t want a passive role in this process. I created three possible solutions to ensure a safer and fairer workload, however there was resistance from some of the consultants. Why would they change the roster when it’s so convenient for them? They would take the other registrar over to the private hospital to help with their operations, and leave me at the public hospital to run the unit. They most definitely did not want the ENT registrar to help because that would mean that they’d have to come in for the operations. With me on call, they could stay at home whilst I did the operations.

    And so everything stayed more or less the same. The other registrar took a generous two whole shifts off my load, but the revised roster that he distributed showed that I would be working for 19 consecutive days in June, and 21 consecutive days in July. Six senior doctors had raised their concerns with my department, and this was the result. Even my patients started to worry about me. One morning, Mr B asked, “you’ve seen me every day, including weekends… doesn’t this impact your family life?” I smiled and told him, “Yes, but it’s okay. I do it because I love my job”. Both of us knew I was lying.

    On the 1st of June I resigned. It wasn’t okay anymore. I was physically alive, but spiritually broken. At lunch time, I begged the HoD if I could go home. The answer, as always, was no. “Just hang in there”. I felt like I had already “hung in there” for 3 months. The 1st of June was my 24th consecutive day of work, 19 of which were 24-hour on call days. I knew what it would mean to resign – I would be black listed and I would never get a job in Plastic Surgery again in Sydney. But I couldn’t keep going. I crashed my car on my way home.

    At the news of my resignation, the HoD rang me. “Can’t you just finish your term? It’s only a few more months”, said the voice down the line. “I don’t think I can,” I said. “It’s a shame. You have good hands. You’re good at what you do… but if you can’t handle the hours, maybe this isn’t for you.” And that was that. The chilling final words from my HoD.

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