My transformation from medical student to doctor was so gradual and subtle that I was hardly aware it was happening. I was completely absorbed in what I was learning and observing, internalising it until it became a part of me. We had come in as innocents with big dreams, and gradually over the years we were moulded into the kinds of doctors who would exemplify the high standards and international acclaim of UCT Medical School and Groote Schuur Hospital.
It was only when I was on the receiving end – as a patient – that I was able to appreciate how far I’d come. I had gone to an orthopaedic surgeon for a minor procedure on my foot. On the day of the surgery he casually rested his hand on my leg as he talked me through what he planned to do. I stared at his hand resting there, how at ease he was touching me as if he knew me. I realised that I did that with patients too – touched their shoulder to reassure them, rubbed their backs when they were in the throes of painful contractions in the maternity unit. I had seen how the senior doctors touched patients, how they connected and questioned, how they probed both physically and verbally. I was becoming one of them.
Our training was rigorous. In addition to the whole-class Friday-afternoon lectures, we attended tutorials and ward rounds in small groups, and we were assigned patients to examine and present. Our end-of-block exams had both theoretical and practical components; it was the practical exams we feared the most as they brought us face to face with Groote Schuur’s most esteemed clinicians. It was terrifying to stand in front of an examiner and present the clinical findings of the patient you’d seen, and then field questions related to the particular disease. You knew you were doing well when the examiner’s questions became increasingly obscure, even gravitating to the fine print of medicine such as the originators of eponymous clinical signs like Dupuytren’s contracture or Cushing’s triad.
Sometimes this attempt to mould us into world-class doctors was more brutal than it needed to be. Humiliation was an integral part of the way we were taught; it was accepted and indeed expected that at some point during your studies a specialist would grill you in front of your peers – and even patients – in a manner that left you feeling exposed.
As students we were at the bottom of the formidable Groote Schuur hierarchy, with its associated oversized egos, rivalry and one-upmanship. Some fields were more revered than others, certain specialists more specialised than others. A few of the egos were monumental; one lecturer we simply referred to as God for his inflated sense of importance and infallibility.
The students and junior doctors bore the brunt of the venting of egos. I witnessed one particularly memorable incident at Mowbray Maternity Hospital; I was in my fourth year of study and I was working with a newly qualified intern. We had been on call overnight and during the morning ward round the intern, Samuel, gave a report on the patients we’d seen. He was soft spoken and hesitant, and as we moved from patient to patient I sensed the gynaecologist’s growing irritation. The tipping point came towards the end of the round as Samuel gave a brief account of the clinical findings.
“On examination the cervix was five centimetres dilated,” he said.
The specialist interjected sharply. “If you are going to stick your fingers in a woman’s vagina you better say more than the cervix is five centimetres dilated!”
Samuel stood frozen, and then fumbled as the team of doctors and students waited for him to say more. He hadn’t documented his findings thoroughly, and he was at a loss to give the specialist what she wanted. For the next five minutes we all stood around the patient as the specialist detailed his every omission and dismissed his clinical assessment as shoddy at best.
The specialist was correct in calling him on his oversight, of course. I think many of our teachers were motivated by a desire to produce doctors of a high calibre, who were meticulous in relation to their work. The manner in which they did it, though, sometimes did more harm than good.
I managed to escape the more brutal attacks; there were petty little humiliations along the way, but none that left any lasting impressions.
As exemplary as our training was, I feel it was inadequate when it came to the hands-on procedures. As a doctor you are often required to perform procedures during the course of your work, from simple tasks like putting up a drip to more invasive procedures like putting an intercostal drain into the chest or a central line into a neck vein.
We were never formally assessed on our ability to perform these procedures. The maxim on the wards was simply: See one, do one, teach one. You would shadow a senior doctor, watch them, and then you were deemed fit to perform the procedure yourself. Of course the hope was that the person you were observing knew what they were doing and that by the time your turn came to teach, you would have perfected your technique enough to pass it on to someone else. There were some procedures I never had the chance to learn while at medical school, and only encountered them as a junior doctor in busy wards and casualty units, where the senior doctors seldom had the time to oversee what I was doing.
One of our lecturers, a trauma surgeon, used to say: “Don’t waste time on the dead or dying.” This, like see one, do one, teach one, was one of the dozens of maxims that defined our lives at medical school and the way in which we were trained. We learned to ask intelligent questions and to really listen, even to read between the lines when making our diagnoses. One adage that particularly irked me – not only because it was blatantly sexist but also because it too often proved true – went: A woman is pregnant and lying until proven otherwise. Though crude, this was intended to remind us to always bear pregnancy and its associated complications in mind when dealing with female patients. This served me well on many occasions later in my career.
It certainly came in handy when I saw a young woman during my community service in Khayelitsha. She was seventeen years old but her slight build and fresh-faced prettiness made her look a lot younger. She came in alone and was hesitant as she settled into the chair next to my desk.
“Hello, sisi,” I began. “What can I do for you?”
“I’ve got pain in my stomach, Doctor,” she said.
“How long have you had this pain?” I asked.
“A few weeks,” she responded.
Pregnancy alarm bells went off in my head. “When was your last period?” I asked.
“Some months ago, Doctor,” she said.
“So you’re pregnant, then?”
She shook her head. “No, Doctor.”
I paused. There was a level of sincerity in her eyes that told me she genuinely didn’t think she could be pregnant.
I tried a different approach. “Are you on any form of birth control?”
“No, Doctor.”
“Do you have a boyfriend?”
“No, Doctor.”
“Are you sure?”
“Yes, Doctor,” she said earnestly.
I suspended that particular line of questioning as it wasn’t getting me anywhere and I elected instead to try to uncover other possible causes for her symptoms. I came up with nothing. She had persistent lower-abdominal cramps and she hadn’t had a menstrual period in over three months. Pregnancy seemed the most obvious diagnosis but she was so adamant that she couldn’t be pregnant.
I asked her to lie down on the examination bed in the room. Sure enough, as soon as I placed my hand on her abdomen I felt a mass arising from her pelvis that strongly suggested a gravid uterus, about fourteen weeks’ gestation. The pregnancy was confirmed when I tested her urine.
Sadly, I don’t think this young woman was lying when she told me she couldn’t be pregnant. I suspect she had very little knowledge of how her body worked; she may even have been impregnated by someone who wasn’t her boyfriend, which would explain her strong resistance to the possibility of what I was suggesting.
My training attuned me to the clinical clues that told me what my patients feared to utter.