Why I left private practice for the public sector

Some of the greatest psychological stressors are said to include breakups, death, moving house, and starting a new job. Sometimes we choose one or more of these willingly, and hope to hell that the payoff will be worth it.

For two years, I worked in private general practice in Cape Town. The benefits of this kind of employment were sizeable – I made a living on relatively few hours, and had no overnight calls. I got to sleep like a normal person! I had a flexible schedule, and could always increase or decrease my hours as necessitated by my needs.

67f7caa11c6a92df0d63d283d90ddcd7The cons, however, were not insignificant. Any leave I took – sick leave, vacation, or for a course/conference – was unpaid. I was paid by the hour (and that has affected my taxes, too). I was often the only doctor at a practice, sometimes one of two. The patient-pressure was immense – I never managed to get a grip on seeing 4-6 patients in an hour. I simply was neither able nor willing to compromise patient care, nor my medico-legal accountability.

On the other hand, I did get to live in Cape Town. Cape Town! Although the city can be scary and inhospitable to newcomers, there is so much to do. I could never tire of it. As Murphy would have it, I made a lot of friends and found communities to slot into during the final few months.

But why did I ultimately decide to pack it all up, and move AGAIN?

Because I was miserable.

I am not going to unpack that misery now (maybe another day), but I soon found myself completely out of love with my work. I missed the sense of a team. I missed being able to discuss cases with colleagues, and having someone with whom to commiserate. I missed the somewhat academic environment of public hospitals. I care a great deal about primary healthcare and public health, but I found that I was swimming against whitewater rapids, and treading water was becoming more difficult by the day. Although I wasn’t working very many hours, I found myself constantly low and tired. Often, I would delay leaving for work until the very last minute, and then arrive late. My career seemed hopeless; I felt heavy and inert. 

In short: I hated my job.

I do not use that term lightly. In previous jobs, I had certainly had days when I hadn’t particularly enjoyed working. This was not that. Hating my job is probably one of the worst things that has ever happened to me, and unless you have experienced it, you cannot begin to imagine it (I certainly could not). I have very clear memories of LOVING being a doctor before, so I know that this had little to do with my profession, and more with the direction I was taking and the environment I was in.

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And now I get to work scrubs to work every day!

So when the call came to offer me a job in anaesthesia, the scales weighed heavily in favour of the new job. There was the matter of the city and the people I would be leaving behind – and I did not make that decision lightly. Ultimately, being unhappy at work was negatively impacting on all spheres of my life. I had to get out, or it would kill me.

And so, I said yes. I packed all my belongings for the fourth time in three years, to move to a small city with significantly fewer resources.

But I think I am happy here. I have completed two months of supervised work, and I am starting to have my own independent theatre slates. It has been extremely high-stress, and my confidence has on numerous occasions hit the very bottom of rock bottom. I often fall asleep on my couch in the early evenings, because my brain feels so fried from all the mental exertion.

But I love my job again.

And I cannot begin to explain what a game-changer that is.

My Advice for Your ComServe Application

It’s almost time for the asynchronous community service applications in SA, and shortly thereafter the regular applications will begin. So I thought I’d take a break from dispensing medicine, and dispense a tip I could have used:

Apply somewhere that is going to challenge you.

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Zithulele, Eastern Cape, where I went in my final year for Family Medicine. A fantastic Community Service option.

Apply somewhere that you will be expected to work with a reasonable level of independence. Probably the best place to do community service, in my opinion, is somewhere that you can do emergency medicine, or at least your overtime in emergency medicine. Yes, even if you don’t want to do EM in the long run.

Why? Because EM will teach you independence. EM will teach you how to think on your feet. And EM will give you plenty of experience with emergency situations in whatever specialty. Everywhere I have applied, emergency scenarios have formed part of the interview.

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While at Zithulele, I even got to assist in some basic eye surgeries.

This advice comes from experience. I was lucky enough to get my first choice for ComServe: a highly specialised children’s hospital. But it was also a safe choice. At that stage, I wanted to do paediatrics as a career. I was going to do a Diploma in Child Health, and I’d be set. Except… I’ve since changed my mind. I still love kids, but paediatrics isn’t my first choice anymore.

It’s not just that. Because I was in a highly specialised setting, I was not encouraged to act independently. We always had backup close at hand, and we were expected to make use of it. And while I’m thankful for a great many things during that year, I’ve noticed that in job applications, I’ve been at a distinct disadvantage. I’ve lost a lot of the skills I gained in internship, while my peers have been able to build on theirs. I’ve been studying up as much as possible, but as we all know, theory is a poor substitute for hands-on experience.

fdd3f4239b2c7ad6feb3d86aa29083b5A year in EM would have been especially beneficial to me, because of my self-confidence issues. I know that I know how to do certain things, but my lack of self-confidence often means that I hold back. More experience in EM would have forced me to dig deep and take ownership of situations.

So apply to that rural post with limited resources. Apply to that busy hospital in the township. Apply to that day hospital with an overflow of trauma. (Just make sure you have some support, like a psychologist, for regular debriefing.) It’s one year, and it will only benefit you in future.

Read This Book: In Shock by Rana Awdish

“If empathy is the ability to take the perspective of another and feel with them, then, at its best, the practice of medicine is a focused, scientific form of empathy.”

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For the past few days I’ve been devouring In Shock in every spare moment I could find. In her narrative, Awdish recounts the experience of severe illness and near-death on the background of being a physician herself. She shares almost “crossing over”-esque insights into how and why medicine is failing its patients, as well as its doctors.

In Shock is definitively part-memoir, succinctly conveying the many complexities of Awdish’s illness and survival. True to its intention, it avoids the traditional stiff-upper-lip clinical retelling, and allows for range of emotions experienced by the critically ill individual. It is a narrative not looking purely outwards, but also in. What Awdish distills from her experience is both poignant and pragmatic.

“Illness is viewed as an aberrant state. It is a town we drive through on a journey home, but not a place to stop and linger.”

In Shock is about medicine’s broken telephone. It is about our inherent, but often unintentional, disrespect for patients and ourselves. It is about seeking comfort in the wrong ways, and about righting our bad medical habits.

“We listen imperfectly, through a fog of ghosts and competing priorities.”

Perhaps an unexpected benefit for me, in reading this, has been clarity. I understand now the dissonance between myself and much of medicine – I think my generation of doctors exists in that grey area between the “old-school” and the “new school”. We’re trying to remain respectful of the giants that brought us here, but have also become acutely aware that the way things “have always been” is not the way things should continue.

While I think that anyone can enjoy this book, I highly recommend it to medical students and doctors. I’m definitely adding this to my growing list of books medical students should read, right up there with Postmortem and When Breath Becomes Air(If you do read it, I would love to discuss it with you.)

Right now, I am absolutely fangirling over Dr Awdish, and I wish to see more physicians like her speaking up. Far from being punitive, In Shock invokes the hope that medicine can be healed – and so, too, can we.

“In that light we can accept that our greatest gift is not in fact healing, because all healing is transient.”

… I’ll leave you to read it yourself to discover what our true greatest gift is.

General Practice and Emergency Med: A Bad Combination

Since the beginning of the year, I’ve been working semi-permanently for a private family practice. More recently, I’ve also started doing shifts in the emergency centres of both private and public hospitals.

While doing each of these separately comes with their own challenges, doing them together has proven to be a demoralising combination, because they highlight the failures of each field, and our inability to fix them.

Being a good general practitioner is damn hard. The pressure to see patients quickly is high, and spending 15 minutes per patient is the norm. This means that a lot of health promotion cannot happen. It takes a while to counsel about smoking cessation, when the patient’s reason for visiting is a stomach bug. Perhaps you tell the patient to come back for a Pap smear (because her consultation time is up), but she never does, because she can’t afford another consultation.

And if you want to do health promotion in the waiting room, all the pamphlets are sponsored by some or other pharmaceutical company, so that becomes an ethical grey area.

Emergent patients come to their family practitioner because they don’t want to sit in a queue at the local hospital. The GP sends them to hospital anyway, and the patient has lost R350 (at least).

In the world of Emergency Medicine, we are often faced by the failures of primary care (in state or private). We see the effects of uncontrolled hypertension and diabetes. We get flooded by inappropriate “green” referrals or walk-ins, because patients are tired of not getting results from their GPs. And seeing these “greens” takes valuable time from the very sick patients. (There’s that “distribute justice” they spoke about in medical school.)

The Emergency Centre isn’t there to fix the myriad problems our patients encounter. So we take their bloods and send them to their primary care physician to follow up – on their cholesterol, their high blood pressure, their smoking, their lack of recent Pap smear, their obesity…

To add insult to injury, their is a strong mutual dislike between general practitioners and emergency physicians. Working these two jobs results in a huge cognitive dissonance for me, despite the insight it offers.

I am increasingly desperate to get a more permanent job in a state hospital, in a department I like. Please cross fingers with me.

Tips for New Interns: First Week at Work

Last night I worked my last shift for Community Service. 1 January 2018 will mark three years since I walked into my first day of work. And on that day, more than 1,000 new interns will enter our workforce.

I remember the nerves the night before: being unable to sleep. Feeling like a fraud, like I had been allowed to graduate by accident. Worried that I would be labelled Worst Intern Ever; worried that I’d have awful colleagues. But I survived the first week, and eventually the first year, too.

And so will our new interns. I have some tips for those who need ’em.

64062aa6fd8336df8d9536c250fadde7 Continue reading “Tips for New Interns: First Week at Work”

Are We Secretly Our Own Worst Enemies?

If you’ve been reading South African news, you’ll know that at least 300 interns and community service doctors stand to be unemployed next year, due to a lack of funded posts at accredited institutions.

Perhaps you read about our inhumane working hours last year.

Perhaps you have read about the overflowing hospitals where patients pile up in the corridors.

These are not new problems, we just hear about them more because doctors and patients have phones with cameras, and social media accounts.

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Continue reading “Are We Secretly Our Own Worst Enemies?”

Working in the Land of Milk and Honey

I recently realised that some of my posts have disappeared into thin air. I’m not sure how, but I’m reposting them courtesy of the web archive.

By some kind of dumb luck, I am doing my Community Service posting at an incredible children’s hospital in Cape Town, rather than the archetypal middle-of-nowhere clinic post we all expect for ComServe.

And it’s incredible.

This hospital is just something else. It’s public, but has so much private funding that it might as well be a private hospital. It gets a lot of private patients so clearly I’m not alone in my perception.

Some things that continue to blow my mind: Continue reading “Working in the Land of Milk and Honey”