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One of the things everyone is afraid of, on starting medical school, is how they will deal with the horrors of the job. Will the sights and smells of the dissecting room make you sick? Will you faint in theatre? Will you be overcome with revulsion at the first infected wound, or burst into tears at the first death?
It’s a reasonable anxiety. Many of those things happened to many of us, at some stage in medical school or after. I never quite fainted, but I was made to lie down on the theatre floor by an experienced scrub nurse who had noticed me turning slowly greener and greener as the first incision was made.
But it passes. It passes astonishingly fast, for nearly all of us. After just a few weeks of experience, we mostly find that we can regard the goriest injury or the grimmest tragedy with – not quite equanimity, but at least with composure. Perhaps we don’t stop minding, but an element of routine seeps in around the horror, and blunts its edge.
This professional armour, though, can turn out to have chinks in unexpected places. In the middle of something quite ordinary and insignificant, you let down your guard and, out of nowhere, the human distress we work alongside every day is sharply real again.
Dystonia clinic, on a Wednesday morning. Most of the patients are regulars, and many have come for Botox injections – for blepharospasm, torticollis, any of a range of disorders of muscle activity, not dangerous but painful, disfiguring and intensely annoying. The treatment works well, but needs regular top-ups, and some patients have been coming for years.
The lady in front of us, in her early 70s, is one of these: she attends every four months for an injection to treat her spasmodic dysphonia, a disabling hoarseness caused by abnormal contractions of the vocal cords.
‘How did you get on last time?’, asks the consultant. ‘Did your voice improve?’
‘Well, Doctor,’ replies Miss Smith. ‘Living by myself, you know, I didn’t get much chance to try it out.’
And there it is. Nothing dramatic, no blood or guts, juts a reminder of the utter, desperate isolation that so many older people have to accept as normal. No opportunity to try out your voice – no-one at all to talk to, about anything, for weeks together. We can fix the dysphonia, but what use is a perfectly-modulated voice if you have no opportunity to speak?
You get used to the obvious stuff. You learn to brace yourself for the full-thickness burn or the bereaved parent or the motorbike crash. It’s the little things that slip under your guard.
By the Secret Doctor
Read the blog and follow @TheSecretDr on Twitter and on Facebook
don't they just
Everything changes in this world, all the time, except this principle. (Aristotle). It is better to change with change and not get stuck where you are. Dr Bashir Qureshi; Ambassador BMA.
Agree with th blog.
My first hole-in-the-armour as a medical student was in the neuro-specialist, trauma centre ED. It was not any of the horrendous gory injuries or terrifying neurological conditions, but an older gentleman brought in in rhabdomyolysis, with severe sacral pressure sores from lying in the same place for so long, neglected. What got me was the toenails, which curled back into his toes from lack of cutting.
I was horrified that our society could allow such a dereliction of dignity. It floored me, and it still does.
In psychiatry, I found many mental health professionals doing incredible work, accustomed to the awful conditions people were living in, and decided I never wanted it to be normalised. I always want the dehumanisation of others to be shocking. It should be shocking. It should get through to us.
I agree. So touching. most times we just leave this out of the way as we have many other cases to go through in the clinic. But if you think about it, it is depressing.
The fact these moments resonate so profoundly I think is both disheartening, in that we need such armour at all to get us through the daily struggle (which I find isn't usually the patients at all - it's those old dragons of IT failure, no beds, staff disagreements etc.) but also encouraging that underneath all that keratin and cicatrisation, you can still see moments of compassion emerging from even the crustiest, most cantankerous physicians and surgeons.
Is it so unnatural to let that armour fall in a controlled fashion rather than letting such chinks shatter our composure? That dystonic patient likely had been in that clinic for more than a few visits - do we really know our patients beyond their diagnosis and current management plan? Our armour can sometimes hinder forming relationships with our patients, which is the foundation on which trust is formed. The more we practice conscious compassion in our care by relaxing our guard and placing ourselves in our patient's position, the better we can serve the people who place their trust in us.
My armour fell off and well, I am lucky to be alive. I cried at work, and was criticised, (not acceptable for a man to cry at work...from a very senior clinician and ex manager) not helped. Please seek help early if you feel that armour weakening. As doctors we shoulder so much misery often related to internal politics and resource issues, (as well as delight at helping our fellow humans), that some of us break before we realise we are broken. We are, in my opinion the last to help each other, perhaps because we don’t wish to admit that personally we are vulnerable given a “perfect storm”.
Over the years the chinks come and you wince or, internally (or possibly externally) howl, then patch them up. I suppose that when you run out of patches is when it's time to retire
Chinks in my armour? Definitely need them. As Leonard Cohen said, 'There is a crack in everything...that's how the light gets in'
Darryl Ballantyne-Watts, Consultant Psychiatrist
It is a very good idea to consult with a health care provider if you have any questions