July 2015

The Medicine

Love, fear and hierarchy

By Karen Hitchcock
What role does ego play in medicine?

The first teacher I fell in love with was the fill-in librarian. I was in Grade 4. I’d finally finished the moronic “class readers” and had thus earnt access to the library, a vast wonderland I had no idea how to navigate alone. I trailed along behind the librarian as she slipped novels from the shelves and handed them to me one by one. The world turned humid. I thought my heart might explode. The next was a laconic cardiologist in his late 50s with a full head of grey hair. I was a third-year medical student on a cardiology rotation. I’d stay back late, and we’d go over the electrocardiograms, or watch the echocardiograms of the hearts I’d listened to on the ward that day so I could see if I’d correctly diagnosed the murmurs. He had broad, strong hands, a bone-dry sense of humour and nothing more important to do than see patients and teach. He knew everything, could do anything. He must have known. Sometimes he’d meet my adoring gaze and his mouth would freeze mid-word, his finger hovering over the ECG. But then he’d clear his throat, straighten his big square glasses and point out the missing QRS complexes: the reason our patient was passing out.

I think now of that old cardiologist and I know it was not exactly him I loved. It was what he offered me: the knowledge and the skill. I remember, so when some intern starts following me around like a puppy with a wagging tongue, I don’t feel flattered. I know it’s not really about me.

Medicine is a practice you learn by apprenticeship. Lectures, assignments and exams are necessary, but you get the actual know-how from your bosses on the wards and in the theatres. The bosses: dozens of individuals living their own smooth and rocky lives, with their bell-curving interpersonal skills and their own genealogy of masters. From them you learn how to be.

There’s no fuel for learning as potent or as combustible as love. Except perhaps fear: of personal humiliation or of killing someone. Without fear or love motivating all of this work, there’s just the strict hierarchy to keep patients safe. Despite a lifelong allergy to authority, as a junior I felt mostly protected by my low standing: I was drowning in uncertainty and ignorance and constantly thanking God the buck didn’t stop with me. There’s a lot to be said for the value of humility in a discipline where you’ll never, ever, know it all.

I once had a bright fifth-year student attached to my team. During ward rounds I’d be explaining to the patient some planned investigation or treatment, or gently broaching the idea that they might die, and she’d leap into my every pause with chirpy re-explanations or repeatedly interrupt me mid-sentence with an unskilled authority that was breathtaking. I took her aside, told her not to interrupt me and explained that I paused not because I was struggling for words but to give the patient time to think or speak. The next day I discovered she’d switched to my male colleague’s team. When our paths crossed she’d look at me with pure hatred. I can imagine what she told her friends: “Dr Hitchcock, that total bitch.” I could have savaged her, insisted she get her arse back on my ward round, but I let it pass. And my colleague – tall, nice suits, very charming – said she never interrupted him once.

It can get very intense with all that raw and fallible humanity crashing about as we move through the wards in ordered formation – all day, every day, trusting that everyone is relentlessly giving a damn. All so you don’t find yourself in front of a dead patient’s husband, saying, “I’m so sorry she bled to death, sir, but ‘we’ forgot to check the haemoglobin.”

If you believe the headlines, intimidation and bullying are endemic and widely condoned in medicine: they’re basically our modus operandi. That’s not true, though they occur. And if you stuff up catastrophically, no one expects it all to stay polite.

Power is so easy to abuse or forget. As a boss you always get the best seat and go through the door first. Your trainees think you know it all, and if they don’t think that they’ll pretend they do to score a good reference. How easy it would be to believe you actually are amazing. How easy to take your mid-life crisis into the late-night private tutorial and demand that she-who-adores-you-for-your-know-how tend your flagging ego.

It’s terrible, really, to think of all the ways we tend a powerful person’s ego: the insincere compliments offered; the behaviours excused out of fear, love or hierarchy. Respect morphing into pander, demanded or not: dutifully laughing at some esteemed professor’s endless, unfunny jokes.

I once knew a great surgeon, short, fiery and fierce. He was one of the best in the country, did heroic, unthinkably dexterous things with a scalpel. Registrars trembled in admiration and fear. In the middle of a ward round he’d often eviscerate the less-favoured trainees. In theatre he might yell and insult them. He was a total prick, but there was no one more skilled at taking a knife to your belly. There’s probably one roaming every large hospital: periodically uncontained and grandiose, always technically brilliant. Medicine’s miscreant rock stars. Witnesses to his performance would look at their shoes till he was done, because this little sadist was also the man who’d taught them, nurtured them, screamed at them, then rescued them (and the patient’s life) when they were elbow-deep in someone’s guts and didn’t know where to cut next. The bullied junior is sacrificed to love, fear and hierarchy – the very three things that make the entire system work.

Karen Hitchcock

Karen Hitchcock is a doctor and writer. She is the author of a collection of short fiction, Little White Slips, and the Quarterly Essay Dear Life: On Caring for the Elderly.

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