Mirenagate

Full disclosure - I have unashamedly stolen "Mirenagate" from Dr Eric Levi. (@DrEricLevi) He has also written a great blog on this piece, specifically as it relates to social media. Aussie medics on twitter especially, would be aware of the article posted in the Australian newspaper on the 2nd of January relating to obstetrics and gynaecology trainees. The article related to a debate topic at a college branch meeting in the next month about women in training and how they should manage their fertility. As one might expect, the suggestion that childbearing should be regulated for the course of specialist training was not taken very well by a lot of people. In fact, it was so badly received, it left a lot of people asking why in the world someone would let the debate topic exist in that form.

I should take this opportunity to point out that a number of obstetricians suggested that the debate topic was supposed to be a humorous way of talking about a serious topic. The RANZCOG president was quoted as saying he wasn't aware of the topic, thought it was tongue in cheek and will address it. Even with that in mind, people were still not exactly impressed. And remain so; this has really struck a nerve.

"Mirenagate" has really brought to light a few issues, all of which are very important and some of these issues have failed to been addressed not just in this scenario, but by medicine for years.

Women have long suffered innuendo or genuine discrimination in medicine due to their reproductive choices. I know of women who lied about their children existing, were bullied when they fell pregnant during training, have been given no consideration due to illness during pregnancy, have worked heavy rosters up to the late stages of pregnancy, been asked about their intentions with children for references/training intentions and so on. And let me very clear, not all of this happened in surgery. It is rife in medicine, I'm sure in a lot of professions, that women may be perceived as having less entitlement to a career or a position due to pregnancy.

Now I understand that this is not always the case and that employers and colleges have been understanding to some groups or people. But to women who have suffered bullying or discrimination by virtue of their gender of their children, it's not hard to see how even in jest, this suggestion could be very offensive.

My friends and colleagues who have undertaken training with RANZCOG have spoken highly of the support they have received when they have had children. The RANZCOG policies are more robust than other training institutions for part-time and interrupted training. If they are going to truly talk about the difficulties for trainees, employers and the college alike when interrupted training exists, then that is a good thing. However, the choice of topic title may have been better stated to take into account the large numbers of women who have been the subject of bullying and discrimination in medicine. The very public RACS investigation and media coverage on this same matter in 2015 should have taught us that we have a group of doctors who have been terribly treated and harmed in the pursuit of their profession.

The other issue that Mirenagate uncovered was the importance of being the master of one's own domain. As often is the case, this story was all over Twitter very quickly. Unfortunately, it seemed that RANZCOG did not have a social media presence here and missed many of the issues raised and the extreme disappointment at this issue. I tweeted my own disappointment, especially in the setting of my perception that RANZCOG was doing better than most. This topic also started off a conversation online of the difficulties many women have faced in training, not just in obstetrics but surgery, medicine and other professions. Not all of the backlash online was directed at RANZCOG but was a sharing of other's experience with pregnancy in medicine. Being online, RANZCOG may have understood what all the fuss was about.

Having a social media presence I feel is not only important for individual doctors, but this demonstrates how important it is for RANZCOG or other colleges. They may have been able to mitigate some of the damage early on. They (and other colleges) could get a strong sense of what a difficult issue this is for a lot of doctors and hear some of the stories women were sharing. Being involved or observing the conversation can allow important change to take place. It is important to be a part of the social media sphere to control the conversation people are having about you, to you or that involves you.

I hope that RANZCOG have a great meeting with meaningful discussion about issues their trainees face. I would also hope that we all learn from this experience. Some of us will learn that obstetricians, by and large do not want their registrars to have Mirenas. Some of us will understand that the media love a headline. Some of us will learn about the struggles faced by trainees and how we can provide better training for our doctors. And definitely, I know RANZCOG will now be tweeting a little more.

Medicare is sick

In case you have missed it, the Australian government is undertaking a review of Medicare, or more specifically the Medicare Benefits Schedule. The MBS is a list of codes for procedures or consultations, delivered by health care professionals that have a cost associated with them. Social media has been quick to pick up on a slightly underdone news report by the SBS about some procedures that are set to be axed. Let's be very clear about something. Medicare is sick. This country is in desperate need of a wake-up call that the public (and to a lesser extent, private) purse is not a bottomless pit, even for vital services such as health care. The MBS desperately needs to be properly and thoroughly reviewed with appropriate values assigned to procedures and delisting of procedures that have no scientific basis. We need to start rationing the health care dollar in order to get the best from it.

We are all healthcare consumers and we should all care where our money is being spent. Think of it like this. While we are wasting money on one thing, say a procedure that may not work, that money could be missing to find a procedure that does work. It's like buying a pair of jeans that don't fit properly, then when you go to buy some that do, the cash is not available. Our entire country should start thinking about how we spend our money and ensure we get bang for a our buck.

The MBS has been around since 1984 and currently lists codes for around 5700 procedures. Some procedures that are still listed are no longer utilised as they have been superseded. Not all procedures are what we call 'evidenced based' where the best possible scientific evidence has been examined to determine when, where and for who we are supposed to use a certain intervention. Some procedures are grossly overpriced and some procedures are grossly underpriced. The MBS has become a matted tangle of codes for procedures that have not been revised since their addition. At the same time, medical care has been advanced and refined. Medicare is also poorly structured to account for the complexities of chronic care and the increasing complex problems doctors manage in modern times.

The review is long overdue. Doctors are commonly heard to be lamenting the complexities, inaccuracies and redundancies in the MBS. It is important that this review becomes an important tool in modernising our medical system and maintaining a high level of care to patients. It is also important that this serves as a reminder of responsible use of the healthcare dollar; that is to say that we as a community spend an appropriate amount on procedures that are both safe and efficacious. I hope that review continues to be strongly influenced by clinicians, those with much more experience and knowledge than I have. Doctors are very happy to be a part of system that reflects the excellent health care that we can provide our patients.

Militant doctors and angry lawyers have rights too

You may or may not be aware about the upcoming, likely, strike by junior doctors in England over a contract that would compromise the safety of patients and doctors and cause severe financial penalty. All this to a vocation that gives so much of itself, for the service of humanity. It is with interest that I read this article written by Simon Jenkins, lamenting how society will be held to ransom by 'militant doctors and angry lawyers' over a contract that Judkins feels is more than fair. I mean, why should society bend over backwards when in the NHS "consultants worked to their own schedules of convenience and remuneration"?

Well, aside from the mythical skills that professionals are using to befuddle the public, according to Jenkins, doctors are a bunch of whiners who are taking up arms on social media and are the new unions, being held to account by nobody and resorting to workforce crippling tactics.

Why is it that professionals, like doctors and lawyers, are not allowed to negotiate and make demands for pay, like any other worker? Why are we not allowed to stand up for a true worth? Is it acceptable that a doctor could be rostered on for 24 hours or more and be responsible? People like Judkins are more interested in their pilots sticking to safe work hours than their doctors.

Medicine is a fundamentally altruistic profession. I'm not sure people realise to what extent doctors sacrifice and go without in order to do their job - helping other humans. It is a lifelong sacrifice and a labour of love for the people and for the profession. Unfortunately, a proportion of the public will always see doctors (or any other professional) as elitist, golf playing, champagne drinking snobs who have it good. Nobody would deny you for a second that by and large, people who have had the means to obtain a professional degree have had a degree of privilege, but make no mistake, that means squat without hard work and extreme dedication.

Irrespective of whether you believe that doctors are kind hearted souls, the fact remains that we have rights as workers just as anyone else does. It is also important to remember that these rights also protect the rights of the patients. Safeguards for working hours are meant to protect doctors from being too tired and therefore making mistakes. Or killing themselves. As a junior doctor, I remember a young obstetrics registrar being killed in a car accident after having worked some unholy hours. I participate in rosters where doctors are rostered on for 24 hours. Back to the pilots, they can't fly this long. Are we more afraid of flying than of not surviving a heart attack? Because statistically, the later is more likely.

Worker's rights are not just for tube drivers in London, or nurses or train drivers in Melbourne. They're not just for blue collar workers who are going to be exploited by their fat cat employers (extreme sarcasm). Workers rights are for everyone. And in the case of junior doctors, they really are for everyone, because who wants a tired, unhappy and undertrained doctor?

It's time we stopped cutting down tall poppies. Professionals are people too and deserve as much protection as anybody else. And in the case of doctors, your life just may depend upon them one day.

We have doctor maldistribution not just a doctor shortage

Disclaimer: This is a broad and sometimes, personal overview of the medical workforce problems. My views do not represent any professional body I am associated with. They also do not even scratch the surface as to the gravity of this issue. I was recently hearing about the growing concerns over graduate unemployment with only 68% of university graduates finding full-time employment within four months post-graduation. This number excludes those doing research or further study. It does include people who may be termed 'under-employed', people who are available for and want to work full-time but are unable to secure full-time employment.

Medicine has always had an aura of being a very secure job. In fact, we are being constantly told by the government that we don't have enough doctors. And while that may be partially true, it is not the whole story. We have a doctor distribution problem, not just a major shortage. We have doctors in towns, in tertiary hospitals but not in rural towns, or certain specialties are under-subscribed.

We are fast heading to be following in the footsteps of our tertiary educated colleagues, where doctors will be unemployed or underemployed. And I'm not referring to a graduate in their early twenties. This problem is going to affect people who have finished specialty training, who are in their mid-to-late thirties and have families and other commitments. We are turning our future doctors into future Centrelink customers because we can't seem to get the balance right.

Rural doctor shortages

One of the major reasons the government wishes to train more doctors is to address the shortage of doctors in rural and remote towns. As a young medical student and junior doctor attached to rural towns, the pain the residents felt at not having a regular doctor or long waits (weeks) to see the GP was incredible. A number of initiatives have been undertaken to try to get doctors to rural towns, including bonded medical positions, increasing medical school intakes for rural students and financial incentives. A number of doctors have also called for the creation of a permanent rural medical school to encourage those graduates to stay in the area.

Rural doctor shortages are in effect, a maldistribution issue. We simply cannot under the current system, staff doctors for all rural towns. It is a very complex problem and has significant concerns for inhabitants of these areas who feel underwhelmed by the medical care.

Do we train too many medical students?

At medical school, my graduating class was approximately 100 strong. That number tripled within a few years. When I went back to university to teach anatomy as a graduate, instead of the few students we had in a group when I did the same unit, there were now sometimes over 10. In 2005, there were 1320 graduates. In 2013, there were 2944 (from Medical Deans data). There are predictions of a doctor shortfall in the range of 2500 in the year 2025. And so, there is ongoing and mass increases in medical schools, not just by numbers at the same university but new medical schools. The most recent addition has been of Curtin University in Western Australia, which will commence in 2017, much to the distress of young doctors everywhere.

I believe that decreasing reliance on overseas trained doctors to fill spaces is important. However, it takes up to ten years to train a specialist doctor, a little less (but not much) to train a GP. With the increase in graduating medical students, we have created a serious bottle neck at the vocational level. Another maldistribution. We don't need more interns, we need more specialists, especially in under-serviced areas like psychiatry and radiation oncology.

The intern crisis refers to the fact that every year, the government struggles to find intern positions for medical graduates. To be fully and unconditionally registered as a medical practitioner, a doctor must complete one year as an intern in a supervised post. So if you could not be employed as an intern and therefore not meet this requirement, you would not be registered and therefore be able to practice as a doctor. The government is always super pleased with themselves when they announce that they have found jobs for all interns. But they fail to mention that we now stick interns in every nook and cranny of the hospital, in jobs that did not exist before or in huge numbers in one speciality, thus risking diluting experience. The job guarantee ends here. Following this, a junior doctor can find themselves unemployed or underemployed as further vocational positions are not made available.

Without taking steps to increase the number of vocational training positions, we are creating a bottle neck for these junior doctors. Again, unlike counterparts from other tertiary degrees, are significantly older and caught in a system that they cannot do anything about. We have not increased training positions for these young doctors to go on and become specialists (including GP) to solve our workforce shortage. But it keeps happening throughout training too, because on the other side of specialist training, things are not at all rosy.

Our medical specialists are underemployed

In the past few years, my friends and colleagues who I have studied with at medical school have completed their specialist training. They are anaesthetists, surgeons, physicians and so on. I am also in this group. We suffer similar angst to medical students, because a number of new specialists are coming up against another bottleneck; the fight for a consultant position.

For surgery, workforce planning has been done on working out how many surgeons we need per 100,000 people (amongst other variables) and taking into account a retirement age of 60. Which is ridiculous to be frank. Any workforce planning, except maybe professional sports, that believes the retirement age is not going to increase is kidding itself. People are living longer, working longer and financial interests have changed. For instance, the GFC saw a number of previously retired doctors return to work as superannuation losses hit home. Our senior colleagues are not retiring, private practice is nearly impossible to break into and we have not at all accounted for this.

We are going to see an increase in junior doctors applying for training positions that simply do not exist. And I believe that we are currently training too many specialists. How can we justify the personal and community expense on training a specialist and have them underemployed or forced overseas at the end? Just to put in perspective, for surgical training, I spent anywhere between $10,000 to $20,000 a year out of my own pocket. And this does not take into account the societal cost of training a specialist. What a waste if we can't actually employ these specialists. There is a significant maldistribution between specialities and as such, some of us specialists are facing uncertain futures, with nobody stepping up to the plate to better plan and coordinate training in this country. The HWA workforce planning document alludes to this problem in 2012. In 2015, little has changed.

So what next?

I don't know. This problem is so complex and it seems we are in an incredible mess. But I think we owe it to our graduates (of university and specialist training) to sort some of this out. Some solutions may have more than one benefit, such as the introduction of part-time or interrupted training. This would allow flexibility that people now desire for families or research whilst allowing us to train more specialists over a longer time frame. Revising workforce planning so that the specialist colleges get a handle on what they're setting its Fellows up for. We need to better incorporate the presence of IMG's into workforce planning. Although we wish to decrease reliance on overseas trained doctors, this will not stop them from coming to and working in Australia. The senior consultants may need to look at ways of adding their younger colleagues to practice in a way that is financially, intellectually and clinically sound for all concerned.

I am also a firm believer that we need to give doctors (especially young ones) more strings for their bows. I think we should encourage doctors to pursue other avenues of study including law or business to allow them the ability to take on management roles for example. And this can only mean good things for hospitals who will benefit from well-rounded physicians and better run hospitals.

I wrote to my local MP (who is now our current Prime Minister) to express my concerns earlier this year. I received a pro-forma email back entitled 'Education' because clearly my concerns best fit into an 'education' problem. The email spent more time talking about women in STEM (also identified as a feminist from first email clearly) than about why improving doctor training issues was important. The email closed with an invitation to get in touch again if I desired. I did reply, and funnily enough, my second email has not been responded to.

I think it is time for the doctor maldistribution problem to be tackled in a meaningful way. Or else the next time you get a taxi, it may be driven by a doctor.

What I've learned outside of my comfort zone

Despite being what most people would call extroverted, I actually find it quite tricky to meet new people. Especially when I’m not sure if we have anything in common. I’m not sure they will find me at all interesting or will we have anything in common to talk about. So, these past few days, I made the trip to our nation’s capital for a little thing called an un-conference known as Junket. Junket has been organized by Junkee, an online magazine who wants to serve politics and culture in a way that respects the intelligence of it’s readers. They invited 200 of young Australia’s best and brightest minds to talk about issues that mean something to them and put it to the brain trust to solve.

The Junket delegates comprised of Aussies across the nation who are from every field imaginable; tech, healthcare, science, engineering, arts, politics, skateboarding and robots even. And the conference was not in any way like anything I ever go to. There were no suits, no planned-months-in-advance schedule. Just inspiration.

I have met some incredible people. I met Young Australian of the Year Drisana Levitzke-Gray, who is deaf and an amazing advocate for the deaf community and introducing AusLAN far and wide. We chatted about the use of AusLAN interpreters in healthcare. There was accountant student Chloe, who wants to teach financial literacy and get doctors to the country. Bridi is a post-doc fellow at Black Dog Institute who is tackling suicide by connecting people. Amrita is an incredible dancer and choreographer who taught us how to dance like Beyonce and wants to preserve Aboriginal culture in a digital age.  Mikey is the first professional skateboarder I've ever met and he wants kids to get active, preferably through skating. Jessica who is a paralympian (in two sports, no less) and is trying to get people to look after their precious eyes. I ran a session with the delightful Laura, who organizes TEDxSouthbank and is heavily involved in philanthropy. And there's Sophia, a super clever Women in STEM champion, Olli who uses her day job as a model to publicise important political messages and Neil Ackland of Junkee who wants us to switch off to get connected. And that list doesn’t even scratch the surface.

This is a group of people I may not have otherwise met. Whose ideas and diverse day jobs, skills, hobbies and opinions I may have never gotten to hear. I think if I go away from this with a broadened view, that is wonderful. I had never even considered some of the solutions opened up by talking to other delegates. While our politics and opinions won't always match up, what the two days taught me is that mismatching is okay, sustainable and necessary to progress. Broad representation is the key.

This is precisely why this is an incredible place to be and an incredible idea. As I heard someone say here, when we put the same people in the same room, they will come up with the same ideas. With different people in different rooms, we have changed the conversation already. We may even be able to change the progress we make with all the very, very important topics we presented. We were so lucky to access each others' networks, expertise, ideas and experience to keep our ideas and solutions headed in the right direction.

The thing though that will stay with me, is that Australia is in very good hands. Passionate, intelligent, motivated and unwilling to accept the same busted ideas. Just here, there is a group that just wants to make the world better. I am so inspired to have just been here. And I am thrilled to have been thrust out of my comfort zone to meet some incredible people.

Still can’t dance like Beyonce I’m afraid.

What is a junior doctor?

At the moment, our counterparts in the UK are under attack from the government regarding their contracts. In case you have missed it, the government is forcing a new contract on 'junior doctors' which will lead to:

  • Reduction in pay of around 30%, in part due to normal working hours including evenings and weekends
  • Financial penalties if time is taken off for say, having children or performing research
  • Loss of protection from unsafe working hours

Although half a world away, the battle hits very close to home for all doctors. The health minister, Jeremy Hunt, has been bending statistics and scaring the public to make them think junior doctors are lazy and money hungry. It would appear that it is the other way around, as while the NHS is figuratively starving to death, the MP's have still received a 10% pay rise.

Australia has a better but still very imperfect system. You would be hard pushed to find a doctor in Australia who hasn't had a problem with pay or working conditions. We have been unpaid, refused overtime pay or rostered for unsafe hours. However, at the moment, we're not in the terrible predicament the NHS docs are. Half of the problem, I feel, comes from calling it a 'junior doctor' problem. Referring to any doctor as 'junior' is a misnomer and belies the countless financial, personal, professional and educational contributions made not only by the doctors, but their families too.

A junior doctor refers to anyone who is a fully qualified doctor but is still in the process of attaining a qualification in a specialty. It covers wide ages ranges from doctors in their mid 20's to well, the sky's the limit. It covers doctors one year from medical school or doctors ten or twenty years from medical school. It covers doctors who have attained their specialist qualification and are fully registered with medical boards, specialty colleges or Medicare as specialists but haven't got a permanent consultant job yet, either because we have a bottleneck for positions or because they are continuing to gain experience in super sub-specialised areas.

If you come to hospital with a heart attack in the middle of a night, the first person you might see is a 'junior doctor'. If your heart stops beating, it will be 'junior doctors' who will start it again. It may be a 'junior doctor' who takes you to the cardiac catheter lab and starts performing the lifesaving procedure to restore blood flow to your heart, while the consultant makes her way to the hospital. They are helped by another 'junior doctor' who gives an anaesthetic and keeps your body in optimal condition. It is the 'junior doctor' in intensive care who will be monitoring your heart rate and blood pressure, talking to your family and reassuring them and informing them.

It takes at least ten years to train as a specialist but during that time, a 'junior doctor' is no less valuable to society, to patients and hospitals. They are still accumulating expert knowledge and spend many, many unpaid, unrecognized and unforgiving hours honing their craft, performing teaching or administration all to one basic end. We all got into this because primarily, we like helping people. We love technical and intellectual challenges too, but we really just want to take a disease and kick its butt.

I think the term 'junior doctor' is a serious understatement of how important 'junior doctors' are. I would prefer something like pre-specialist. Or specialist in training. Or down right legends. Because that is what junior doctors are. They deserve respect and protection like any other occupation or person in society. They deserve to be able to pay their mortgages and their training fees. We seem to have lost our way as a society with where our respect goes. Put out a sex tape and become 'Instafamous'? Money and fans and respect are yours. Study for over ten years, work like a dog and sacrifice? The bureaucrats will ensure that your are undervalued and underpaid.

Superstar doctors of the NHS - we are with you 100% of the way. Good luck!

The standard we're all walking by

The Royal Australasian College of Surgeons recently released report by the External Advisory Group (EAG) was a damning look into the culture of bullying and harassment in surgery. In an unprecedented move, Professor David Watters, in his role as President of RACS, issued a public apology to those who have been bullied by surgeons. At the moment, we are awaiting the final EAG report where recommendations will be made into where to from here to stamp out bullying and harassment. I am impressed that RACS took this step in the first place. Surgery has a terrible reputation and the EAG report has unfortunately, upheld that. But where is the rest of the healthcare system? Where are the other specialty colleges, allied health, nursing, medical administration? RACS, if they continue on this pathway of addressing harassment, have an opportunity to be leaders. But it cannot be done alone.

Hospitals are a melting pot of different beliefs, ages, genders, races, backgrounds and experiences. It is natural that there would be interpersonal conflict. And there is. Whilst surgeons may well have learnt themselves a pretty bad rap, on a day to day basis, people from all walks of life are making someone else miserable. Since the report has been released, I have very rarely heard anyone else say that their specialty or profession or hospital are prone to bullying and harassment. I haven't seen (at least not well publicised) another speciality college saying that they will follow the lead of RACS and investigate bullying and harassment in their own specialty too. The hospitals have just carried on, business as usual.

Bullying happens everywhere in hospitals. I don't know what it is. The list of episodes of bullying and harassment is extraordinary. From the pay office who 'forget' to pay junior doctors to the senior nurse who likes to push around the interns. There was the time a senior physician commented about how women shouldn't be allowed to do surgery. There was the surgeon who liked to treat his theatre nurses so poorly, they had such a rapid turn over. A senior nurse was suspended for bullying her juniors, only to return to work. Some of these things, I've seen happen. Some have been stories from other colleagues at various times and at various hospitals. And quite often, the solution is to do nothing. Even those with some power do nothing; problems with staff members, especially if not your own, go in the too hard basket. And quite often, young doctors are told not to make a fuss, not to stand up for what is right because 'it may affect their career'. Even senior staff members within hospitals will freely admit that there is a problem, with an individual, a group or a culture then follow up by saying 'it's not worth the trouble'.

I agree, standing up for what is right may have negative consequences on the career  prospects of an individual. You are thought of as a trouble maker. And very often, as was identified with the RACS EAG report, a power differential exists. People have great ways of making your life miserable within the hospital environment. Despite this, one thing I am truly sure of. That is that the current standard of behaviour that we are accepting in our hospitals is definitely harming our staff members.

Again, I am going to refer back to doctors, but I would be quietly confident that this happens everywhere. Why would anyone subject themselves to constant stress? Good people leave. They leave that hospital, they leave the public health system, some leave healthcare all together. What's crazy about this is that the perpetrators, the system sees that as a win. But I can tell you it is an enormous loss. The people who care enough to say when something stinks can be our greatest assets, trying to change the status quo.

I worked with a colleague several years ago who was an extraordinary doctor. They came up against some difficulties with their training body and was not at all supported. This brilliant young doctor left the hospital system altogether. The people who made life difficult were pleased to have a problem out of their hair. The public should mourn this loss for we have lost a brilliant physician who was just beaten down by the constant fight just do a job.

So, now that the EAG report is out and RACS has been held responsible, I would like to see every area of healthcare take this lead. They may not need to commission an independent report, but I would like to see some of the recommendations made carry over to every other specialty college and healthcare profession. Surgery may have learnt it's stripes but let me assure you, that is not the bounds of the problem. It's time to stop walking by an unacceptable standard or pretending that your s*** doesn't stink. It's time for a multi-pronged approach to bullying and harassment in our hospitals. I hope that I can say in the future, that I am proud that RACS, my college, led the way on this and that we all rose to the occasion.

Toxic hospitals: when workplace culture has a bad attitude

I have been asked on a few occasions why I chose to do cardiac surgery. Aside from the subject matter, the technical challenge, the real difference you can make to someone, it was the team work. At the hospital where I started my training, I was lucky enough to work with a wonderful team. It made me appreciate how each of us, as cogs in the larger machine, came together for a common end. I hope my colleagues felt the same, but to me, it was collaborative, collegiate, sometimes fun but above all, healthy. We didn't always get along, nor did we always agree. But it was a kind of functional chaos that I have not really seen replicated. With the release of the Royal Australasian College of Surgeon's EAG report on bullying and harassment in surgery, the focus on what is a good workplace is at the forefront of our minds. Even just in day to day life, there seems to be a shift in how people perceive others' behaviours in the hospital work environment. Could it be that we are becoming emotionally intelligent about what makes a workplace healthy and what makes a workplace toxic.

A toxic workplace is a workplace that negatively impacts on the welfare, productivity and wellbeing of employees. In the healthcare sector, there is an added and vitally important group at risk - the patient. If we are too busy bullying, bitching and being obstructive to one another, aside form our own health, we are risking that of the very person we are there to save.

Toxic hospitals are horrific places to work in. Every day is a constant battle to get what you want or what you need from your workplace. What you want or need might be to be treated fairly. Or it might be appropriate instruments. It might even be teaching or support or holidays or rostering support. People go home every day exhausted, emotionally and physically. And they leave to greener pastures. But a toxic workplace or coworker doesn't see this as a loss. They prefer maintenance of the status quo - people who don't challenge the culture.

Toxic workplaces are often deeply engrained with practices of bullying and harassment, fuelled by toxic co-workers. These individuals and consequently organisations don't always see their practices or behaviours as problematic. You probably recognise these workplaces by their battle cry - 'we've always done it like this' or 'nobody else has had a problem before'. As a consequence, enforcing change is so difficult. Look at surgeons for example. It took a very public exposure of these practices in surgery to begin a paradigm shift.

I want to make one thing very clear. Surgeons have as I said, been exposed and held to account for its past practices. And they should. The rest of the health care system needs to follow suit. Toxic coworkers should not be tolerated. The sooner hospitals who have toxic work environments admit they have a problem and take steps to rectify them, the better. And the more people who stand up to toxic coworkers and toxic workplaces, the better for us, the employees and of course our patients.

As a final note, if you are interested in reading more about toxic work environments, I would highly recommend reading 'Toxic Coworkers' by Alan Cavaiola or 'No Asshole Rule' - all excellent places to start with to build a healthier workplace.

It's a man's world, baby.

I attended a function recently with some of the best and brightest female minds in medicine. After we discussed the medical topic at hand, conversation turned, as it often does, to gender issues in medicine. In a room of around twenty bright women, there was not a single dissenting voice to say that they had not found gender to  be an issue during their careers. As you may realise from reading this blog, I am a bit of a feminist. I believe that gender roles still very strongly define the lives of Australian women. I recently re-read Sheryl Sandberg's fantastic book, 'Lean In'. Actually, I listened to the audiobook because that's how I read these days, it uses my travel time very well. I found myself nodding enthusiastically at the impostor syndrome, the tiara syndrome, the fact that men are chosen on potential, whilst women are chosen on past achievements. I realised the importance of how women act or perceive ourselves (and each other). Sheryl Sandberg is a COO for Facebook and a graduate of Harvard Business School but even in the humble auspices of medicine, without a 'corporate ladder', it still a man's world out there.

The Impostor Syndrome is alive an well

I really think sometimes that I am here truly by accident. I wasn't actually meant to get into medical school because I'm rubbish at maths. And well finishing medical school, I just pulled the wool over someone's eyes. As for my specialty training, I am waiting for them to call me up and ask for it back, a mistake had been made. Turns out, impostor syndrome is everywhere in medicine. A quick chat to my female colleagues revealed an incredible amount of unfounded insecurity about their achievements. This is from a group of wonderful women who are bright and caring and ambitious. Truly, we have no reason to believe that we don't deserve it, yet we are constantly acting like we don't.

Sexism sells (us all short)

Just two days ago, a male physician approached me and said something along the lines of 'Are they letting girls do cardiothoracic surgery now?'. He seemed to think this was hilarious and followed up by saying 'That's not sexist is it?'. A few years ago, I might have laughed off the comment or made a joke but not that day. That day, this man got schooled as to my qualification and the sexist tone of his remarks. His response? 'Well good for you.' Good for me? It's bloody brilliant for me, actually. It's bloody brilliant for anyone who has made any achievement, especially with short sighted remarks like that. While it may seem amusing or cheeky to say things like that all the time, it's really neither. All that comes from that kind of remark is us both looking like idiots. Me for doing a 'man's job' and you for your short-sightedness.

Double standards

One thing Sandberg references in her book is that women don't ask for promotions or needs to be met. Partly because we think we will be denied, or don't deserve it or worse yet, judged for it. If you do need to ask for something, there is a right way to do it if you are a woman. Be humble, be community-minded. My female colleagues experiences seem to echo this. Rather than asking for a day off when heavily pregnant, one colleague pushed on through until the late stages of pregnancy. When she finally asked for a day off or some leniency for the on-call roster, she was told 'oh no, please don't get upset!' A male colleague who had a physical illness (not pregnancy) was given leniency on the on-call roster, days off, you name it.

Women are our own worst enemies

Everyone knows that if you put a whole bunch of women together, there's too much oestrogen and things get catty. I don't watch it, but I understand that is the premise for the Bachelor? Although they fight tooth and nail through hardship of being a female in a male dominated profession, not all women mentor their young female counterparts through the same positions. Women will make it father when we stop competing and comparing, whether it be the workplace or socially. Lift as you climb, ladies.

I think that we are all susceptible to subtle and sometimes unconscious expressions of gender bias. I am also saddened that in a room of professional and successful women, so many of us have experienced this. Nobody has the right to make us feel inferior for who we are, including ourselves. I can't way for the day when we have equity and strong female role models are not such an endangered species. The #ILookLikeASurgeon and #ThisIsWhatWeLookLike campaigns are already making so much ground in shattering stereotypes and providing inspiration the world over.

Medicine is a man's world baby. And it's a about time we changed that.

Women's troubles: why women still come second in heart disease

I love a bit of Barbra Streisand. The woman spells her name without an 'a' just to be different. One of Barbra's finest films is Yentl, based on a short play about a young Jewish woman who upon her father's death, pretends to be a man to be allowed to study at a Jewish religious school. Barbra won the Best Director Golden Globe for this film, the first woman to do so. So why are we talking about early 1980's films? Well, Yentl syndrome was first described by Dr Bernadine Healy to describe a phenomenon where women are more likely to be underdiagnosed, under-treated and die from the heart disease from their male counterparts. Women who present with typical or atypical symptoms of coronary disease are much less likely to undergo diagnostic coronary angiography (where dye looks at the blood vessels of the heart to see where they are narrowed) or be started on medications we would normally deem necessary for a patient with heart disease. Now this is not a gender-based discrimination problem, but rather a problem in biology. Men who have coronary artery disease tend to present with fairly typical symptoms like central chest pain, have big or obvious blockages of big coronary arteries and then therefore go on to get the appropriate treatment. Women, on the other hand, have atypical symptoms like tiredness, atypical chest pain or shortness of breath that may not trigger an angiogram. If they do have one, it is more likely to demonstrate what we term 'microvascular disease' where tiny blood vessels are blocked and may fall outside of the abilities of diagnostic tests or treatment.

Currently, the Annals of Thoracic Surgery has an article in press entitled 'Comparison of 3-Year Outcomes for Coronary Artery Bypass Graft Surgery and Drug-Eluting Stents: Does Sex Matter?'. This study, by Hannan et al seems to show that we do have a gender difference that is a little concerning.

The study looked at a group of men and women who had had either coronary artery bypass surgery or a stent for their coronary disease. As with most studies, there was more than double the number of male patients in the study. But each gender was then divided into two equal groups; those who had surgery and those who had a stent. The group then looked at how many people survived, had another heart attack, a stroke or another procedure to unblock the coronary arteries. The idea was to see whether men or women did better with heart surgery versus stents.

There is a noticeable difference between the men and women patients. For patients undergoing heart surgery, the mortality rate for women was 11.8% and 8.0% for women. A similar trend was seen in those getting stents. The women who had stents had a 13.7% rate of death, the men 9.1%. Similar trends were seen for strokes, heart attacks and needing another procedure.

While this study was not set up soley to look at how women performed to men in treatment, there is quite a noticeable gender difference. This is supported by a growing body of evidence that suggests all of the things I mentioned earlier. Women present later, get diagnosed less, get undertreated and do poorly when the have heart disease. For a condition that is killing women more frequently than cancer or any other disease, we seemed to have underperformed in both studying why and translating this to better care for women. Again, this not a discrimination thing, this is a biology thing. But one thing is abundantly clear, we desperately need more work and much more attention into women's heart disease.

References:

Hannan et al. Comparison of 3-Year Outcomes for Coronary Artery Bypass Graft Surgery and Drug-Eluting Stents: Does Sex Matter? Annals of Thoracic Surgery 2015. Article in Press

, , , , , , . Factors influencing underutilization of evidence-based therapies in women. European Heart Journal. http://dx.doi.org/10.1093/eurheartj/ehr027

Update: #ILookLikeASurgeon going viral

A very quick post: The Huffington Post has put out an article about the 'I Look Like A Surgeon' campaign and I am very appreciative that mainstream media has picked up on it. The Daily Mail quickly followed it up with a very large article solely on me and pulled pictures from my blog to fill it up. As thrilled as I am that DM picked this up, the article is put together from quotes pulled from the Huffington Post and social media, not from any of my direct comments to them, nor give explicit permission for use of any images, quotes or the like.

I am very flattered that the social media campaign has reached such wide audiences. This is not a campaign about, for want of a better term, fame and fortune. It's about role models, solidarity, collegiality and inspiration. In the last couple of weeks, I've chatted with surgeons from around the globe and met some lovely people! I hope people who read what is quite a sensational headline on the Daily Mail website, read the story and the stories of many women who have contributed to the I Look Like A Surgeon campaign.

As trite as it may sound, I became a doctor to help people. And I chose my specialty for it's technical ability, the subject matter is fascinating and for the wonderful people I work with. It was not only the surgeons I worked with that mentored me and inspired me, it's the nurses from my early days as a resident and junior registrar who taught me how to manage wounds or put a bag of fluids up. The anaesthetists who showed me how to read an echocardiogram, the perfusionists who taught me more about physiology than I thought possible. I loved the early morning or late night chats I had with ward clerks, cleaners, secretaries and patients. Because without all of us working together to help me learn and do my job to the best of my ability, I wouldn't be doing my job to the best of my ability. When I finished my training, I know I said to some of those people how thankful I was for their help and teaching, but now I want to say it again.

I do truly want to inspire men and women to do my job. I hope that by all of these wonderful surgeons jumping on this campaign we attract the best and brightest to our profession. And if you want to do this, check out the #ILookLikeASurgeon hashtag on twitter or Facebook - you will find no shortage of wonderful men and women to mentor you.

Holding on for the ride!

#ILookLikeASurgeon

#ThisIsWhatWeLookLike

Why women in surgery need other women in surgery - #thisiswhatwelooklike and #ilooklikeasurgeon

I recently spoke at another university 'Women in Medicine' night. I find these events both enjoyable and educational. It's a great opportunity to meet colleagues and other young women who are studying to become doctors and try and inspire and instruct some students (both male and female) into what I hope will be fulfilling and productive careers.

But every time I get ready for one of these talks, two things go through my head. The first being that I have no idea what they really want to hear. I had some very good advice that they just want to see that we women surgeons are real and that it can be done. (Turns out that is true) The other thought I have is how relevant is this anymore? After all, over half of medical students in a number of universities now are female. And then...

Whilst waiting to talk to a patient on the phone "Hang on, the nurse is here to see me" (after seeing them every day for a week and doing the surgery)

From a male physician "Women should just work harder to make up the pay gap. And because they have time off for children."

From a colleague involved in conflict resolution, man (and recent) cases of women in distress due to discrimination in the workplace, resulting in illness or leaving the profession.

Let's be honest. In my country, I won't be injured or killed for walking down the street with a man who is not my husband. I can drive, I can vote, I can be educated and I can be gainfully employed. When you look at things that way, I am very fortunate. However, this does not mean that we don't have some problems with the way our society views and sometimes treats professional women. Whether it be medicine, corporations, politics, law, trades or engineering, women are by and large, a minority group. Which means that for younger women wanting to join the ranks of the patriarchy, finding someone to identify with is pretty difficult. And we know that gender plays an important role in mentoring in medicine.

As a junior doctor, my mentors were male doctors. They were and still are, excellent mentors and I am very appreciative of their guidance. In fact, on several occasions, they were insightful and sensitive enough to make sure that I was aware that some unique challenges may face me in my career and made sure that I was equipped to think them through as part of my career and life planning. Sometimes though, I really wanted to know how that actually played out for someone like me. I was very resolved to the fact that I was to some extent going to have to carve out my own path in life. And I have been okay with that.

There is some research around that by and large supports the availability of women mentors for young women doctors and medical students. Gender matching can have a very positive influence on a mentor-mentee relationship with the 'mentee' being more comfortable to seek out advice from a mentor of the same gender without worrying that gender will colour the perception of the question or the advice itself. What it may boil down to is as simple as my talks for women in medicine nights. We just want to see that it can be done and learn from a mentor's journey.

Finding a female mentor, in surgery especially, can be tricky. Finding any mentor can be tricky. It is a relationship like any other, where both party needs to be satisfied with in order to work. When we have a lack of women on a a sheer numbers basis, finding a gender equal you identify with can be really hard!

Social media has been awash in the last few months with campaigns and hashtags such as #thisiswhatwelook like, a campaign created by an anaethetist and a philosopher to challenge societal and professional ideals of what professional people look like. It's extended to virtually every profession and skill you can think of; CEO, drummer, programmer, lawyer and surgeons. I got on board pretty early with my 'This is what a surgeon looks like' t-shirt and it's been great fun to be a part of. Recently, engineers joined in with a hashtag #ilooklikeanengineer when a young woman apparently was not considered to be what we would consider 'looking like an engineer' and has crossed professional lines to surgeons with #ilooklikeasurgeon now trending. And I love it. Being a part of this feel inclusive, inspiring and just fun. In the last few months, I've chatted with women surgeons around the world about surgery and not about surgery. But by and large, it's been about positive change and positive role models. It's about changing perceptions and expectations and encouraging young women into a profession that we all love.

   Every time I talk about being a woman in surgery, I want to achieve a few things. Firstly, I want to show people that I have a cool job and inspire others to maybe try it out. I love when a junior doctor (male or female) tells me they've loved cardiac surgery and now they want to do it. Secondly, I want to share that you absolutely do not have to be a certain race, gender, personality, sports fan or other group to be a surgeon. In fact, diversifying our specialty to involve women, for example, is a fantastic thing. Every different person has something unique to bring to the table and we should encourage that enrichment. And finally, I want to show the world that I don't have to be a stereotype to be a surgeon. Because I am a surgeon and this is what I look like.

 

Mentors can certainly mentor across gender and racial boundaries. But let's be real, in a world where people can still discriminate or belittle or neglect you like my two short (and very recent) examples, a ground swell against stereotypes can only be a good thing. If I encourage one young woman to be a surgeon just by being one myself, that's wonderful. If together, we can all make positive changes in a society and a system that is imperfect, then that is amazing and is truly an achievement to behold.

#ThisIsWhatWeLookLike

    #ILookLikeASurgeon

  

P plate surgeons - teaching, learning and ethics

The New England Journal of Medicine has published a fantastic article on trainee participation in surgery. The story is told by an ophthalmology resident (registrar equivalent) with a patient, none the wiser that a training surgeon, fully supervised, has just performed successful cataract surgery. The author talks about striking the right balance between teaching and training and what the patient would wish to have happen. Hospitals, especially teaching hospitals, are home to doctors of vastly different experiences. There is the professor, with thirty years of experience on one side of the table. On the other side of the table, there may be a doctor with weeks, months or only a few years experience. It is through this vast experience that an exchange of knowledge and learning of skills takes place. And at the centre of this is the patient.

I have always found that patients, by and large, do not have an understanding of the medical hierarchy. Which is understandable. There are so many words, terms, faces. Interns, residents, registrars, fellows, consultants. Age, or rather a perception of the doctor's age, is one thing I think patients use to try and work out who is in charge or experienced. They may perceive the person they have had the most contact with as the leader or the person who spoke to them for the longest. While I'm sure the patients appreciate that a hierarchy exists, I'm not sure that they always appreciate that there can be a chasm of experience, skill and knowledge between two people.

But whether they appreciate that difference or not, the patient has a most vital and important role in closing that knowledge gap. It is through their illness that junior doctors learn. I actually loathe to use the word practice. To me, that sounds akin to shooting hoops from the free throw line, over and over, hoping you get one in. Refinement. Advancement. Training. That is what it is actually like. A process rather than a crack at the goal. And with an experienced person standing there. I'm not sure during training that we say often enough that we are thankful for the trust our patients place in us. Without them, we simply could not learn.

But we don't say it. Very often, we don't specifically inform a patient that a surgeon in training may perform some or all of their surgery. A number of consent forms have a standard provision that reads something along the lines of 'a doctor other than the admitting doctor may perform the procedure'. As the New England article mentions, the patient may well not consent to a trainee performing their procedure. Which leaves us in somewhat of a pickle. Like so many situations, we have an obligation to more than one person. We have a very important responsibility to protect our patients and their health and well being. And we also have an obligation to train surgeons, for without them future generations would not benefit from medical care.

A number of things are leading to concerns with training young surgeons. Sicker patients requiring true expert intervention, changes to surgical training program execution, excessive working hour restrictions and oversubscription of doctors at certain levels of training. The use of simulation in both high and low fidelity models has been used to teach, develop and refine skills prior to getting to the operating theatre. I had the opportunity to practice on some fantastic models during my training. Paul Ramphal, an American surgeon who works in the Bahamas, has a fantastic simulator that uses a pig heart in a model chest cavity and has engineered in a way that it 'beats'. I had the opportunity to practice coronary bypass grafting on this model several years ago. And it was great fun. There is nothing quite like the real deal, but I think we will move towards simulation more and more as a way of teaching and training. Aviation and sport have made use of such technology for years and medicine is now catching up.

But what about for the now? Well, for starters, in cardiothoracic surgery, the literature seems to support that a patient's operation will not be compromised by having it performed by a junior surgeon. For coronary artery bypass grafting and valve surgery, there have been a number of publications that suggest that the outcomes are similar between a training surgeon and an experienced operator. In my field therefore, I can tell a patient that having a trainee operate should not adversely impact on their outcome. Their grafts will still flow and their valves will still open and close.

But we do need to be more open. And we need to do it such a way that the patient is not only reassured but also happy to be part of a very important process. The New England article makes mention of another ophthalmology publication whereby the authors got 95% of patients to consent to trainee participation by honest and open discussion in the informed consent process. And honesty and openness is so important to not only the consent process but the respect for the patient's autonomy and as a fellow human.

Personally, I think that moving towards transparency is the correct move. I think if I can reassure a patient that their outcome is unlikely to be unchanged, that they will participate in a very important process and of course, that trainee surgeons have appropriate supervision, then that is a process that it is ethically sound. However, I would be lying if I thought that a proportion of patients would decline a trainee surgeon or that all of their anxieties would be put to rest by any open and honest discussion. Going for surgery is scary at the best of times, adding another possibly worry into the mix may not be helpful for some people.

During my training, a small proportion of patients have asked who will actually be doing the surgery. Most of the time, I answered that it will be the consultant they were admitted under. If I knew that I was going to be do that patient's operation, I told them that too. I am very, very grateful for the patients who taught me. Who taught me simple things like placing an IV cannula. To the ones who showed me where their good veins were for taking blood. I am grateful for donor families who trusted me to use their loved one's organs for transplant and to the patient on whom I learnt how to perform joins in arteries with a suture the thickness of your hair. I am grateful for the learning because my future patient's will reap those rewards. But most of all I am grateful that you trusted us, all of us, to look after you when we were still learning the nitty gritty of just how to do that.

The 'B' Word

Bitches get stuff done. - Tina Fey My team had developed a little habit of being late to work. I hate being late, it's just something I really try to avoid doing. For the first four months, I let it slide. But then, I told them all that they need to be on time. I did not name call or swear or shout. But I saw it all on their faces, the raised eyebrows, the downcast gaze. And then, as predictable as death and taxes came the 'B' word. Bitch. How original.

I have been called a bitch for as long as I can remember. And some of the time, it really makes me mad. That ambition, assertiveness, requesting a standard, standing of myself or taking no rubbish from people equates aggressiveness, dominance or is in some other way threatening is the way female behaviour is often skewed. The rest of the time, I wonder what fool would call a woman a bitch if he really thinks she is aggressive, domineering and won't take his BS? Talk about poking a bear!

It's not so much the choice of the word bitch that annoys me, it's what it implies. If a male boss asked his juniors to perform to a certain standard, he may be called firm but fair. If he wanted to advance his career and expressed desire to lead or win or achieve, he would be called ambitious. A woman in those same positions gets called a nasty bitch or a bossy bitch. Why should a woman boss not demand a certain standard? Why should a woman not express ambition to rise through the corporate ranks? What is that is so wrong with this? Why do women get name-called for it?

I'm a bitch, I'm a lover, I'm a child, I'm a mother. - Meredith Brooks 'Bitch'

When you call me a bitch, you turn me into a one dimensional nasty, scheming, domineering and unstable woman. I could be a sweet as pie, laughing and joking, even inspiring for 95% of the time. The 5% of the time I get cross or demand a standard or assert myself and get called a name colours everything else I do. Nobody will seem to remember that 95% of the time. Nobody will ever remember that their actions necessitated repercussions. My team for example, very swiftly forgot that they had mostly been 5-10 minutes late the entire year and that asking for everyone to be on time is courteous to everyone who is.

Once you are called a bitch once, that is all you are. Everyone is waiting through the fun times and laughter to see what I will next identify as unfavourable and 'turn into a bitch' about. A woman who is a bitch is incapable of expressing a range of emotions, of which anger or frustration are normal human emotions. She can only be that one thing from there on out. She has been painted with the bitch brush and that is hard to erase.

Bitch, like a number of other derogatory feminine nouns, is thrown around so commonly these days. It's no surprise that even as children, we use the word bitch and pretty indiscriminately too. Rap songs have been infamous for their use of words such as bitch, hoe or slut. Snoop Dogg, a pretty masculine kind of guy, recently came out and said that with his daughter and mother in mind, he would never refer to women as 'bitches' again. He would be horrified for someone to use those terms to describe his daughter so he should lead by example. And how true is that? We call each other names that if they were used for the women in our life that we care for, we would be furious. But with terms like bitch firmly engrained in our vernacular, is it any wonder that we so freely use the term in a derogatory fashion?

She didn't care that people called her a bitch. 'It's just another word for feminist,' she told me with pride.

By all accounts, Steve Jobs was a hard task master. He demanded excellence from his employees and from himself. When he sadly died from cancer, the world mourned the loss of this brilliant mind and business man. People called him a visionary and a genius. Will we do the same if the world were to lose a bitch? Probably not.

If being a bitch means voicing an opinion or demanding a high standard, then I am a bitch. If it means that you don't take someone's BS and will fight back when insulted, then I'm guilty on those counts too. If you think that I am confident and not afraid to challenge the status quo, then again, I am sorry to say that I am a bitch. And you'd better watch out. Because the bitches of the world are coming. Beyonce, Sheryl Sandberg, Michelle Obama, Hilary Clinton, Oprah Winfrey, Julia Gillard, Julie Bishop, Taylor Swift and Melissa Mayer. The woman executive at the bank, the lawyers, the doctors, the politicians. The small business owner and the athletes. If you are threatened by the bitches of the world, you had better get over that quick smart.

I am not going to say that I am 'proud to be a bitch'. I do my best to be a good leader and although I am not perfect and have plenty of learning to do, I actually think I do an okay job of it most of the time. I am proud to be opinionated and dedicated. I am proud to believe in high standards and I will never apologise for wanting to be good at my job, for wanting the best for my patients from myself and from those around me. I will not let go of my ambition because I am proud of my drive and dedication. I will not admit to being consistently even tempered or sugar, spice and all things nice. I am human and I express anger, sadness, happiness, despair, jealousy, fear and hope, all normal and healthy human emotions. If you want to call me a bitch, that's fine. I won't stop you. But don't be surprised when I use all of my 'bitchy' qualities to succeed while you call the next ambitious woman names behind her back.

As much as I say that sometimes being called a bitch upsets me, I know who I am and I am proud of who I am. If those qualities that I am proud of also get me called a bitch, then so be it. I have broad, bitchy shoulders that should have no trouble bearing the load. I can't wait to be in a workplace with more 'bitchy' women. We're going to do a great job!

Being a doctor is nothing like Grey's Anatomy

1x11Detox
1x11Detox

Do you want this guy as your doctor?

I never really watched medical shows, even before and during medical school. I watched maybe one season of ER, a couple of seasons of Grey's Anatomy and House MD and maybe one episode each of Private Practice, Chicago Hope, Emily Owens MD and other random medical shows. The only medical show I made an exception for was Scrubs, because it was funny and poignant and the closest to replicating what life is actually like in a hospital (but still a long shot I'm afraid!). Oh and I want to be able to whistle like Dr Cox. I'm sure like every profession, seeing your own profession on the big or little screen is generally frustrating because of the gross misrepresentation of your profession, daily life or working environment. Hollywood likes to play fast and loose with facts and science. Entertainment is great and all but that doesn't stop me from yelling at the television 'That's not real!'. So I thought I would compile a list of some of my favourite fictional faux pas.

House MD: You just cannot be addicted to painkillers and still employed. I feel pretty confident to say that if a patient upsets you and you insult them, even humorously and with a razor-sharp wit, you would be in a lot of trouble! Same goes for your colleagues. The medical profession takes substance abuse pretty seriously and Gregory House would have been parked in rehabilitation and his services declined with his opiate addiction. Brilliant as he may be, anyone with such a serious problem would be directed to the appropriate services. And by the way House, it's not lupus. It's never lupus.

House MD (again): Doctors don't do every single kind of procedure themselves, or even at all! Oh wow, this one grinds my gears. After breaking into a patient's house to confirm that they have been lying to you, you take the samples of mould found in the air conditioning vent to the lab where you run a host of tests to tell you all you need to know and save the day. I should mention that this was a follow-up procedure to you individually performing a patient's gastroscopy, brain biopsy and MRI. Does not work like that. We specialise. We outsource to experts. You just cannot be abreast of all of these procedures. It would be like me performing heart surgery and then popping to theatre next door to deliver a baby or administer an anaesthetic.

Every medical show or movie ever: Everyone who has a cardiac arrest gets a minute of (sub-par) CPR and a shock and then coughs and wakes up.  This one upsets me the most because when it really happens, it's not a happy ending. It's really sad explaining to families that we did CPR but things didn't work out. Or that not everyone's heart can be restarted (or should be) with a shock called a defibrillation. The survival for an out of hospital cardiac arrest is around 10%. However, I hope that seeing CPR on TV or at the movies encourages people to learn CPR. It may very well save a life. I'm also thrilled to see so many places now having automated defibrillators. It may give a few people a real chance of making it.

Grey's Anatomy: Interns do not do surgery alone. Even if they are getting it on with McDreamy. Interns are doctors in their first year out of medical school. I remember my intern year so well - it was scary and exciting and so fascinating. I learnt so much and got to do so much. I learnt to put in chest drains, arterial lines, do lumbar punctures and ascitic taps (read: nerdy surgical intern). However, the consultant neurosurgeon or cardiothoracic surgeon is not going to give you the suture or scalpel and say 'go for it!'. Nor are you ever likely to be put in that situation in the first place. Medicine is a skill to be learned over a period of time and we all have to take it one step at a time. Maybe it wasn't Meredith and McDreamy hooking up that promoted her, he probably just couldn't stand her pouting if he said no?

Every medical show or movie ever: There is no McDreamy (or equivalent) True story - when I graduated medical school, my grandmother, ever the feminist, said "well now you can meet a nice doctor and get married and have kids!". I am a nice doctor! Besides, going to medical school is a very extreme form of husband hunting! I hate to say it too, but doctors are a great big bunch of nerds. We don't swan in with our designer stubble and perfect hair or make-up. My make-up is generally found on the inside of my surgical mask so at the end of the day, I'm more McYuck than McSteamy. Doctors may scrub up all right but by and large, work is work and scrubs look good on nobody. Sorry. On the upside, the constant time indoors means we have lovely skin. Winning!

Grey's Anatomy: Cutting your LVAD patient's drive line will not bump him up the transplant list Just won't. It will get you deregistered and probably kill the patient a lot faster than you will ever find a heart. Sorry Izzie. Transplant is a highly regulated and very sacred process and we are not about to screw it up like that. Actually, that kind of thing would probably get you arrested, not fast asleep in your prom gown with your friends looking after you.

Every medical show or TV show ever: Random old school x-rays  These days, we mostly use computers to look at x-rays or CT scans. But why is there, always some random, usually chest x-ray, which bears no relation to the 'patient' hanging up in the background? You don't just leave x-rays lying around a hospital, they'll vanish never to be seen again. And by the way, Betty from Mad Men. Your chest x-ray was pretty darn good for someone with terminal lung cancer.

Pulp Fiction: Stabbing someone with adrenaline in the heart will not cure their OD. I feel like I'm telling a whole bunch of kids that Santa is well, you know. And if John Travolta stabbing Uma Thurman in the heart isn't one of the best damn scenes ever, well I don't know what is. But let me reassure you, that will not work. Now, in cardiac surgery, I have given intracardiac adrenaline before, but that is with and open chest, where I can directly see the heart and when things are not going very well at all. But that is pretty uncommonly used really. Plus, a needle into someone's heart can make the heart bleed, and the bleeding squashes the heart causing a condition called cardiac tamponade. So in reality, about an hour or two later, Uma's heart would have stopped and Marcellus Wallace would have been seriously unimpressed.

Every movie or TV show ever: If you are in a coma, you need a breathing tube, not a little bit of oxygen up your nose. This really grates me. If you are in a coma, you generally cannot breath for yourself. So we put a tube down your throat and breathe for you. Nasal prongs are so seriously pointless and downright negligent. I get it though, the marvellously attractive actor would not look so nice with a piece of plastic down their mouth.

Every movie or TV show ever: 'Flatlining' is not called flatlining, it is called asystole. And it cannot be fixed with a shock. Flatlining is one of those funny lay terms that if you hear being shouted in a hospital, you should turn the TV down. A flat line on a monitor means the monitor is disconnected or the patient has asystole where the heart has no electrical or mechanical activity at all. Unfortunately, this cannot be fixed by a defibrillator shock.

Rant over.

I'm going to start watching legal shows.

Can you have it all?

A few years ago, I spoke at a women in medicine day for a university surgical society. The theme of the day was how to have it all. I felt more than a little nervous. I don't know that we can. But I had decided in fairness to both sides of the debate to try and tell these young women how I try and 'have it all'. What was ironic was the morning of the presentation, I had been called in at 4am for an aortic dissection. What was more ironic was that 5am was when I was supposed to be finishing my talk because I hadn't had time to finish it before then. But I did my best. My opinion was that you can have it all as long as you work out what 'it all' means to you as an individual, family or couple and that it may not all happen at once. A fellow speaker who was a rural GP/surgeon stood up at the end of my talk and wanted to know if I ever 'take me batteries out'. I don't know what she meant by that but she may not have listened to the bit where I said do what is right for you. A friend of mine is applying for surgical training and I fully support her and I think she will be wonderful. We had a bit of a talk last night about one thing that is really worrying her about embarking on a surgical career. That is, meeting someone and having a family. How do you do both? Can you have both? Or do you have to choose?

Women, regardless of professional standing, are more likely to spend more time with household chores and child rearing tasks. If they are married to another professional, for example two doctors, the woman is more likely to forego or change her career to a different specialty that is more conducive to family-related tasks. Even if her specialty is perceived as 'more prestigious'. Women physicians are more likely to be married to another physician while male doctors are not. And when we look at a doctors' formative years, women doctors are a lot less likely to have children than their male counterparts. But it's not doom and gloom, we're not a lonely barren lot. Women doctors are married and procreating at rates comparable to the general population. No need to break out the cat lady starter kit just yet.

I am going to go back to the statement that I made at the university function. Everybody is different. I don't think you necessarily have to pick one thing over the other. It is surgery or it is a family. It is work or it is a marriage. It is operating or exercising. The scalpel or drinks with friends. It is balancing these in a mixture that makes you happy that I think you really need to work out. At the same time, I also don't think that if you for example see family as your number one in life, the thing you will be most whole with and that you're worried how surgery will impact on that, well that's cool. Nobody wants to spend their life in a career that they resent away from something or someone that they love.

I think what I want to say is that I think it's possible to tick all of the things in life that you want. I'm reluctant to say 'have it all' because really, I think that saying in itself is rubbish. But you need to work out what the important things in life are to you. Then it's just a matter of timing.

Sisters are doin' it for themselves: a girl's guide to heart disease

Welcome to June sisterhood! June is the month the Australian Heart Foundation uses as it's Go Red for Women month. A time to raise awareness and funds for women's heart disease. Yesterday was Go Red for Women day and it was lovely seeing social media awash with red as we all remember how scary heart disease in women. A lot of people would be forgiven for thinking that breast cancer is the leading cause of death in Aussie women. But unfortunately, that is not the case. Heart disease is the leading cause of death for Australian women. It's so important that we recognise that and understand that it is not just a bloke's disease. It can affect any of us and unfortunately, if it does, the consequences can be terrifying. Women with heart disease don't fair as well as the blokes. Even in younger women, ladies with heart disease die of the disease more often and have poorer quality of life. Think of quality of life as being able to do the things you need or want to do. Dancing, swimming, walking, shopping, stairs or going to the toilet yourself.

So in honour of Go Red for Women, here is my brief guide to heart disease in women.

Coronary artery disease in women

Coronary artery disease refers to blockages in the coronary arteries. These are the arteries that supply blood to the heart muscle. When these get blocked, you have what is commonly referred to as a heart attack. A bit of the heart muscle dies - this can be a big bit or a little bit. Coronary artery disease kills nearly 10,000 women a year in Australia (compare this with breast cancer which is about 3,500).

The risk factors for coronary artery disease in women are being overweight or obese, high blood pressure, high cholesterol, diabetes, genetics and smoking. See what is interesting about that list? They're virtually all changeable risk factors.

After a heart attack, a number of things can happen. Some people who have a heart attack can die immediately from the heart attack due to an abnormal heart rhythm, a rupture of part of the heart muscle or the pumping mechanism of the heart being so badly damaged. Other people may recover to a point, but some of these people have longer term problems. These can include heart failure which can stop you doing even simple things like getting dressed or angina which are like multiple 'near heart attacks' and can seriously limit how you live your life.

Ladies with coronary artery disease don't do as well as the blokes

I hate to say it but this is one area the men have us covered. Women with heart disease tend to see the doctor later, have it detected later and do badly after a heart attack. This is partly because the symptoms of a heart problem tend to be a little different to the men. Women tend to present with vaguer symptoms like being tired doing physical things or short of breath. The typical chest pain in the middle of the chest may be a slightly more vague discomfort, not even in the chest but in the jaw or arm. As such, the symptoms are not usual and it can be easy for patients and health care professionals to miss.

The way women block their coronary arteries is different to the men. Women have very small blood vessels blocked which makes the symptoms different and the diagnosis and treatment harder. It means that if you are a woman with risk factors for heart disease, you should be vigilant for changes in your ability to do physical tasks, funny niggles in the chest region or getting super short of breath doing things like climbing stairs.

The later diagnosis and later or different treatment mean that women who get coronary artery disease don't do as well. Even younger women with heart attacks fair badly. They unfortunately die from their disease more often and don't recover particularly well.

Modern medicine is pretty cool but not always able to save the day

Prevention is better than cure. It's a bit of a modern way of thinking that if we get sick, we can have a tablet or an operation and everything will be okay. I'm afraid that is simply not always the case. We see patients regularly who have heart disease who cannot have an operation to fix their blockages in the coronary arteries. These patients have to be treated with medicines that don't fix the problem. They're more like putting band-aids on a gun shot wound.

The best defence we have against heart disease is to not get it in the first place. And with modern life catching up with a lot of us leading to inactivity, weight gain, high cholesterol, smoking rates alarmingly high in young women, we need to put the brakes on immediately. Today is as good a day as any to stop smoking, get active and lose weight. It's not easy or fun. Well sometimes it's fun. But I can guarantee you, recovering from heart surgery or worse yet, dying from heart disease is even less fun.

Don't forget about other forms of heart disease

Coronary artery disease is the main offender but not everything. We see a number of women with other nasty heart conditions like heart failure, rheumatic heart disease or congenital heart disease. The number of women with these conditions are growing and doctors and researchers are working tirelessly to manage these growing problems.

Worried? Get checked up.

Like that ad for the national terrorism hotline a few years back, we should be alert, not alarmed. (Who would have thought that phrase would have stuck so much?) If you are worried that you are at risk of heart troubles or have a heart problem, see your GP and get everything checked.

For more information: visit the Heart Foundation Australia website here

And importantly to donate to Go Red for Women: click here

And lastly - watch this fabulous video by C. Noel Bairey Merz about women's heart disease

And - #WeWillBeRed

 

'We don't do that at home' 

I am away at the moment in Fiji with Open Heart International. The organization has been traveling overseas to many countries providing services including cardiac surgery, burns and women's health. This is my first trip with the team and it has been a really incredible time. One of the things I've found myself saying a lot is 'we don't do that at home!'. We don't have mice and geckos on the ward, we don't reuse items that are meant to be disposable (like oxygen masks and nasal prongs and plastic gowns). Our parents sleep on a rollout bed with linen next to their kids in hospital at home. Here, they sleep on a hard wooden bench about 4ft long. There's been a lot of things that we do not do nor do we see at home.

And that is just the tip of the iceberg.

The local villagers did an ask around and came to visit the children and their families I the ward after their open heart surgery. They gave each family $250 (Fijian) to help while their child is sick. We don't do that at home.

The local blood bank has a bus that is run by an ex-pat volunteer. When the locals donate blood, they test them for a wide range of things including kidney function and HIV for free. People here can't afford the blood tests so they get it for free for donating blood. We don't do that at home.

 When doctors train here, they earn a very low wage. Partly because they have to pay back the government for their studies. But when they have finally paid that back, the doctors send the bulk of their earnings back to their whole villages. Most of us don't do that.

We operated on a six year old girl today and her mother left the anesthetic room in tears, worried for her little girl. But her operation went smoothly and she was awake in ICU not long after. Her mother, with tears in her eyes, hugged me so tight. It was all I could do not to cry myself! Some people say thank you at home but that soulful, deep and genuine gratitude. We barely acknowledge each other sometimes. Little or big, thankfulness is something we struggle with at home.

This trip was about changing lives. Operating on men, women and children who will now hopefully go on to lead productive lives in their community, who will grow up big and strong, or who will see their own kids grow up. But really, they change us too. They make us feel the warmth of the local welcoming and gratitude and we will take that back home. Maybe it will be some small thing that we will show gratitude to somebody else for, like the guy who makes your morning coffee. Or maybe something big like your surgeon. But no doubt about it, there's a lot of things I've seen in this little country that we don't do at home. But boy do I wish we did.

At Their Mercy - Doctors behaving badly

The last few months have seen surgeons in particular gain notoriety as tyrannical teachers at best and destroyers of dreams and souls at worst. The 4Corners episode last night entitled 'At Their Mercy' set out to expose some of the terrible behaviour that goes on in hospitals. I only managed to watch it, piecemeal, this evening. The show told the story of Dr Caroline Tan, Melbourne neurosurgeon and Dr Gabrielle McMullin, whose throw away comments (now known as blow-job-gate) at a book launch launched not a book, but a ground swell of support from doctors around the country. The momentum with which the masses have moved to get bullying, harassment and doctor wellbeing on the table and in the minds of people everywhere has been extraordinary. What has been particularly positive is the Royal Australasian College of Surgeon's response. For something that has allegedly in the past been swept under the rug, they have mounted a credible response on this occasion. It may well be in response to media pressure but nonetheless, it is a step in the right direction. When Dr McMullin's comments first came to light, there was a number of people both within the medical community and outside who dismissed her claims as preposterous. This was followed by a very swift and growing counter response from young doctors everywhere who have seen or been bullied, harassed or generally down trodden. It has become very hard for anybody to deny that we have a serious problem here.

The bulk of reporting, including 4Corners, has focussed heavily on surgeons. I suppose it is with good cause. Surgeons have the worst reputation amongst other doctors for being 'difficult'. But let us not forget that bullying and harassment happens not only in all walks of life but within a hospital, from many different groups within health care. Nurses, all kinds of doctors, allied health, medical administration all bully within their craft groups and to others. Junior doctors can be especially vulnerable to insults from all sides. What really needs to come from this process is for any positive changes in surgeons to overflow into the whole of hospital life.

Hospitals are actually the employers of young surgeons, not the Royal Australasian College of Surgeons. As such, they are beholden to provide workplaces that are safe from problems like bullying and harassment. 4Corners touched on some of the alleged problems with the hospital response to complaints, such as those made my Dr Imogen Iblett. The response of the hospital concerned with regards to her complaint was described as manifestly inadequate. The Royal Australasian College of Surgeons has borne the brunt of the media attention but I would definitely like to see a shift to the hospitals, the employers. They too have a role to play. It is not unusual when a doctor is badly behaved for it to be acknowledged that the hospital knew about it and apparently did nothing, aside from a slap on the wrist.

With the now growing acknowledgement that we are in a very messy situation here, I've noticed amongst friends and colleagues a change in how we all look at our own behaviour. Some of us will of course be more insightful than others, but a degree of introspection is occurring. Questions like 'Am I a bully?' seemed to be asked. I would possibly say that if you have enough insight to ask the question, your behaviour is probably okay! But again, a lovely side effect of the media attention is to make all of us aware that the little off the cuff remarks or hard-line teaching may actually be very hurtful to someone. It should make us assess our teaching methods. Hell, it should potentially make us want to learn some teaching methods! A mentor of mine once told me that insight is one of the most important characteristics for a surgeon to have.

Bullying is a little hard to define for some people. Particularly for some of our senior colleagues where there was not just teaching by humiliation but by annihilation. There were racial slurs, name calling, denial of training opportunities. And they were for the most part, shaken off. It was just the way things were. The denial of those kinds of behaviours as inappropriate will only lead to their perpetuation. The philosophy and pattern of 'It was done to me, I'll do it to someone else' rests largely on the premise that I survived it, therefore, it couldn't have been that bad. Today's trainees just need to toughen up. That is entirely the wrong approach. This is not about mental or physical toughness. Yes, there is a degree of tenacity and thick skin that I think you truly do need in surgery. But nobody should have to endure character assassination and racial, gender or other slurs. They are not okay. How would you feel if it was your daughter who had been groped at her workplace? Had listened to sexual innuendo? It would be, I suspect poorly tolerated. Educating our doctors on what is okay behaviour and what is not will go a long way to creating the generational change we so desperately need.

The Expert Advisory Group from the Royal Australasian College of Surgeons has released a survey yesterday to trainees, fellows and international medical graduates (IMG) to truly gauge the magnitude of the problems of bullying. I would implore everyone, whether they have been bullied or not, to complete the survey. I feel very strongly that we need to stand with the College on this matter, whether you trust them, believe them, have been hurt by them or wholly disagree with the existence of widespread bullying or not. They are a group who have a very real chance to make a difference. Whilst it remains to be seen if real tangible change will happen in workplaces, the movement is here. It's in our College, it's in our doctors. Keep the momentum going and let's make our noble profession proud.

Are you okay doctor?

This post contains some strong language. Apologies if you are offended but sometimes, you just need to use something a little stronger.

I hate depression. Depression is a real asshole. It sucks your life force and can destroy you. It is indiscriminate and destructive. The pain depression brings to those who suffer it and those around them is horrendous. I would do anything to reach inside and take that pain away.

I have wanted to write about depression in doctors for a while now. My life and the life of some lovely people I care very much about has been touched by this bitch of an illness. Sometimes with devastating consequences. Beyondblue released a report into the mental health of doctors last year which reported a distressing trend of psychological distress, depression, anxiety and suicidal ideation at levels higher than the whole Australian population. Very few of us were surprised. Take a group of type A personalities and a very high stress work environment and attach some pretty significant stigma regarding mental health and it is a disaster. We all have seen people around as at work who are quite clearly struggling. Some of us are struggling ourselves.

I want to touch a little on my own experience but I hope you will understand that I don't want to divulge everything. My own experiences make me still quite sad and I hate to say it, but ashamed.

A few years ago, I got very sick. A bad job and social isolation in a new town precipitated a change in me so that I didn't even recognize who I was anymore. Gone was a healthy, resilient and outgoing me, replaced by a crappy imitation shell who struggled with some pretty basic tasks like getting out bed, sweeping the floor or doing my washing. I gained 10kg and stopped exercising. Unfortunately, my personality, my genes and my situation collided into a big messy train wreck of a woman. And what is crazy, I knew what was wrong with me long before I actually sought help. I am eager to jump to help my patients or a friend but I couldn't quite make that leap for myself. Which is stupid. But I did and I got better with some help from professionals and friends alike. 

What was messed up was why I let things get a little out of control before asking for help. It was because I thought I was stronger than that. More resilient. That as a care giver, it shouldn't happen to me. I should be better than that. 

Doctors are often reluctant to seek help. There is a fear and a stigma still attached to mental illness in the medical profession that is a significant barrier to getting treatment. Dismissive remarks about how it is weak and that an individual is simply not coping. A friend of mine said recently about someone who was struggling a little that they were having a 'bit of a moment'. A moment? That's an understatement. I cannot for the life of me understand why such stigma exists from people who let's be honest, should know a little better. I suppose like the rest of the world, health care professionals are subject to societal norms and expectations like anyone else. We are after all human.

I really don't understand why stigma around mental health exists amongst health professionals. We are trained to look out for it and treat it. We know that it's a real disease just like coronary artery disease. I would love to see us lead by example. The death of three psychiatry trainees in Victoria should serve as reminder that mental illness is as deadly as any other disease we treat. We as a profession should take this threat seriously and attack it with the same fervor we would attack pneumonia or gall stones. The Royal Australasian College of Surgeons recently partnered with an independent service to provide support to surgeons and trainers and that is a very good step in the right direction.

Doctors need to stamp out stigma attached to mental illness. I really believe that we have a duty to our colleagues to be much more compassionate than we currently are. Depression is not weakness nor is it an inability to the job. It's a nasty bitch who can strike down anyone. We give our patients the support they need so please let's do the same for our selves and each other.

For help in a crisis, please call Lifeline on 13 11 14 or visit BeyondBlue at beyondblue.org.au

Update - a few people have asked me if I'm okay which is so touching. I am fully recovered nowadays and have put the black dog in a kennel where he belongs. I am in charge of my life, not anything else. Thanks for reading.