I was in my element. My analytical mind was amply stimulated by all the theory, though a part of me yearned for the onset of the clinical years when we would put the theory to practical use. Aspects of what was to come were slowly introduced, though in a highly sanitised form. In our second-year anatomy course, we were assigned cadavers to dissect as part of the practical component of the subject. We worked in small groups, and each week we would come back to our designated cadavers to work on a particular part of their anatomy, dissecting the muscles, nerves, vessels and organs that we had read about in our textbooks. In addition to the cadavers, each group was also given a complete set of skeletal bones to study. We spent hours familiarising ourselves with each one, studying the various grooves and prominences where blood vessels and nerves ran and where muscles, tendons and ligaments attached.
We would chat and laugh among ourselves while working on the various anatomical structures; I imagine an outsider looking in on that scene would think they had stumbled on a bizarre satanic ritual conducted by deranged people in white coats. Such was the case when a fellow student’s domestic worker caught a glimpse of a medical student’s often-mysterious learning methods. My classmate Philippa* had taken her group’s bones home, thinking nothing of having human remains in her living space. Unfortunately when her domestic worker came to clean the house she made the gruesome discovery and jumped to the conclusion that either foul play or witchcraft had taken place. The police were notified and Philippa was at pains to explain to them that the bones were in fact her study aids. It was only when the university authorities verified Philippa’s assertions that the police decided to abandon their investigation. The domestic worker was not convinced, however, and she was never heard from again.
At first it felt odd having a dead person on the dissection table in front of me, but that feeling quickly passed. I imagine the brain adapts to these seemingly abnormal experiences, slotting them into compartments so that we are able to attend to the task at hand. This desensitisation was aided by the formaldehyde treatment that the cadavers were given in order to preserve them. It gave the tissues and organs a muddy grey colour and the skin a waxy consistency, and this made it easy to forget they were once infused with life-giving blood. We were never told anything about the cadavers – who they were, where they’d come from, how they’d died – so I guess it was easy to fool myself into thinking that they were never really human.
I never thought to question the wisdom of my being in that environment, given my previous history with death and loss. I was ambitious and determined, and I operated almost entirely from my intellect, disregarding or rationalising away any hint of discomfort that arose. I was so wrapped up in my ideal that even when fate opened the door for me to make an early exit from the medical profession, I failed to heed the warning.
One evening during third year I was required to spend a few hours in the emergency room at Groote Schuur Hospital. I was there as an observer; the exercise was intended to give us a preview of the drama we would face once our clinical training began in fourth year. I stood nervously in the busy casualty unit, quietly observing the buzz of activity around me as patients were wheeled in and doctors rushed from bed to bed, performing life-saving manoeuvres that I didn’t yet understand. One doctor noticed me standing there and she paused momentarily from the notes she was making in a patient’s folder.
“What year are you in?” she asked.
“Third year,” I responded.
“You’ve still got time. Get out, now! I mean it,” she barked before turning back to her work.
At first I thought she was joking so I laughed. But the resignation in her eyes and the desperation in her voice told me she was dead serious. I quickly dismissed what she’d said and forged ahead on my path. There would be countless opportunities that would edge me back to that door.
Fourth year was a turning point in my life as a medical student as it marked the start of the clinical training. From then on the most important learning happened at the bedside, where we learned to connect with the patient, to take a clinical history and to examine the various systems in order to arrive at a diagnosis. We were taught that, just by speaking to patients and examining them thoroughly, we could arrive at a differential diagnosis – a shortlist – of the likely cause of their complaints. Special investigations such as blood tests and X-rays served to exclude certain possibilities and to confirm the definitive diagnosis.
We were based at Groote Schuur Hospital and rotated to various primary- and secondary-level hospitals and clinics in small groups. Each subject was taught over an eight-week clinical block or module, and our rotations depended on the blocks we were assigned. We would all meet back for lectures at Groote Schuur on Friday afternoons, an occasion few of us relished. We were, after all, still young people with active social lives to pursue.
I learned a lot more at the bedside than just the science of medicine. By observing the more senior doctors I got to see that managing patients was much more nuanced than our textbooks suggested. How far to pursue a diagnosis, how aggressively to treat, when to provide supportive treatment instead of aiming for a cure . . . These decisions required a level of clinical judgement that could only come from experience.
Fourth year also introduced us to the complexities of dealing with patients. The doctor-patient relationship requires stepping into the personal space of a patient in a way that you wouldn’t ordinarily do with a complete stranger. Intimacy is established from the get-go, unlike in most relationships where it is allowed to develop over time. In this intimate space you are confronted not just with the organs and systems to be treated, but you also encounter the person behind the patient, individuals with their own fears, hopes and crises. This can be a tricky milieu to navigate, as I learned in my primary health care rotation.
The intention of the subject was to introduce us to a reality that was sometimes easy to forget when working in the confines of academic medicine – that patients’ social circumstances and psychological make-up contributed to the symptoms that brought them to seek help at a health care facility. A seamstress who spent much of her working day hunched over her sewing machine and worrying about the job cuts sweeping through her industry would require a different approach to the labourer whose back pain had come on suddenly and was associated with a tingling sensation down the back of his leg. This so-called bio-psychosocial approach would enable us to be aware of the patient as a physical, psychological and social being and to understand their challenges better so that we would be more equipped to help them.
We were also encouraged to work in partnership with patients in order to bring about the desired improvements in their health. Traditionally the doctor-patient relationship saw doctors positioned at the superior end of a paternalistic relationship. In this role they doled out instructions, castigated patients for perceived wrongdoing and mumbled incoherent and often poorly understood diagnoses in doctor-speak. This did little to empower patients to take an active role in looking after their own health. We were taught to establish a therapeutic partnership in which patients became active partners in the management of their health.
My group was posted at the Heideveld Community Health Centre, where we saw patients at their first point of contact with the health care system. Most had minor complaints, which was consistent with studies that have shown that only one per cent of patients presenting to health care professionals have ailments serious enough to warrant hospitalisation. As I saw patients, I was conscious of the importance of building a therapeutic relationship and I paid particular attention to the psychosocial factors – such as their home environment and psychological stressors – that could be contributing to their symptoms.
On the third morning there a male patient in his early forties came into the consulting room complaining of intermittent chest pain.
“I’ve been here before with this, Doctor, but nobody can tell me what’s wrong,” he said. He looked distressed by this unexplained symptom.
I took a thorough medical history, asking questions about previous illnesses, medication and treatments. In the bio-psychosocial approach it was still important to exclude biological factors related to