Eric Tian

Today marks the conclusion of the MD Student Conference (MDSC), a four day event involving talks, workshops and activities relating to various themes in medicine. While the conference was held in an unprecedented online format, it was enlightening as a whole and there are many insights I’ve taken away from the event.

I’m still processing everything from the last four days, but one idea that struck me was the grey zone of medicine. For most of my schooling, I’ve grown up with a binary way of looking at things. Math answers are either right or wrong. Organic molecules either have a chiral carbon or don’t. Syllables are either stressed or unstressed. There is always a correct and incorrect answer. Things are black and white.

In medicine however, things often aren’t black and white – they’re often grey. For instance:

• What do you say to a terminally ill child who asks you if they’re going to die?
• How confident can you be in a test result with only 70% specificity?
• When do you give up hoping that a patient will recover from an illness?

These questions are difficult and there’s no straight answer to any of them. These non-binary type of problems are uncomfortable, and knowing I’ll have to confront these questions (and more) in a few years is terrifying. If someone could give me a handbook with a blanket answer to these dilemmas, I’d honestly be delighted.

Yet, it’s these situations that make medicine so precious. How can something as complex as a life have clear cut answers when faced with mortality? How do we consider connections to family, friends and the world in this decision? While I have a few issues with the inherent “reactionary” nature of medicine, the sacred responsibility of a doctor to navigate these grey zones is fantastic. And if that results in frustration and burnout, then so be it.

As Paul Kalanithi put it,

“The call to protect life – and not merely life but another’s identity; it is perhaps not too much to say another’s soul – was obvious in its sacredness… Those burdens are what make medicine holy and wholly impossible: in taking up another’s cross, one must sometimes get crushed by the weight.”

Paul Kalanithi, When Breath Becomes Air

Note: All the names below have been changed for confidentiality. Any resemblance to persons as a result of these changes is entirely coincidental and unintentional.

“God, all I want to do is to be healthy again. This sore throat, tight chest, breathing problem, it’s slowly taking over my life. I’ve been to seven different GPs and they’ve all just given me more pills but they make me feel worse! I honestly don’t know what to do… I can’t keep living like this anymore.”

My mind begins to whirl, processing the information as I think about what I should do. Dyspnoea (shortness of breath) could be due to cardiovascular or respiratory causes. Should I ask about coughing to clarify this? Or ask about her past medical history to get a better understanding on what’s going on?

These thoughts are running through my head as I sit in the corner of a small room, amongst three others. It’s my first day on GP placement and I’m currently sitting in the middle of a consultation as a first-year medical student, where my role is to simply observe. In front of me is my supervising GP Dr. M, as well as a young French couple. A few weeks ago, Daphne (the patient), immigrated to Australia from France, ready to start a new life with her partner. However, as soon as she arrived, she developed chest pains, a sore throat and trouble breathing which have worsened over time despite various medical interventions, eventually leading her to us.

I sit quietly and wonder how Dr. M will respond. Seconds pass and to my surprise, Dr. M simply sits facing Daphne quietly, prompting her to continue. A stiff silence emerges and begins to grow, until Daphne breaks it.

“Please don’t give me any more pills… I really can’t keep living like this anymore.”

Daphne breaks down and the room now fills with quiet sobbing. I turn to stare at Daphne’s bursting bag of prescriptions on Dr. M’s desk – a menacing bag, one only weighing a few hundred grams, but carrying heavy connotations of sickness and vulnerability. The silence begins to grow again until finally, after what seems like an eternity, Dr. M stirs. And what happens next I can’t describe as anything but magic.

It starts off with a recognition of the pain that Daphne has gone through – a simple nod, an apology for the trouble that the supposed ‘treatments’ have caused her. “It must be very difficult for you,” Dr. M gently expresses. “To come to a new country hoping for a new life, only to be met with illness.” Teary-eyed Daphne looks up, surprised. “I only came to Australia a few years ago myself,” Dr. M continues. “So I can relate to some of the stress you’re feeling now.”

The tension in the room immediately dissipates. Daphne sits a little straighter and leans a little closer to Dr. M as the questions start coming out. They talk, not just as a doctor and patient, but as fellow people. People with stories unique to themselves, but with surprising and beautiful similarities to others. As Daphne’s explanations become more detailed and emotive, I wonder if this is the first time she truly feels heard. After a few questions (including, to my satisfaction, coughing and past family history), a few examinations and many explanations, a treatment plan for Daphne’s illness is transpired, with clear instructions to come back if the symptoms don’t get better. Daphne looks relieved and I can see a glimmer of hope in her partner’s face.

As Daphne and her partner get up to leave, Daphne turns to me. “I hope you become a doctor like this when you grow up.” I nod and smile in response as they leave the room.

Aftermath

“You know Dr. M, the way you approached the start kind of surprised me. I thought you’d go straight into asking history questions.”

Dr. M smiles as I ask the question but doesn’t stop typing up her consultation notes on the computer. After a few seconds, she turns and addresses me.

“Sometimes, the best thing you can do for a patient isn’t to ask more questions. Often, just being with them, giving them the space to speak and recognising the pain they’re going through goes an incredibly long way. It’s something they don’t really teach you in medical school – the art of empathy.”

Later that day, I think back to my default response to Daphne’s presenting problems. How eager was I to get to the underlying cause of her problems whilst giving Daphne herself no thought? How many of her previous GPs had done the same and caused more harm than good? The art of empathy: by no means an easy or decorated practice, but one which is crucially important. It seems that ancient adage finally makes sense: Treat the patient, not the disease.

“So, the next step in the history taking process is to define the pain. You start this by asking for site, with questions like, “Where are you experiencing the pain? Can you pinpoint the site or is it more general? Does the pain radiate (spread anywhere)?” And if the pain is on one side of the body, remember to ask about the other side – this is important. Got it? Okay, the next step is severity…”

As the tutor speaks, the flurry of medical students typing notes is oddly reminiscent of a waterfall, with myself and 11 other first year medical students taking part in its creation. The class I’m in is called Clinical Skills Tutorial (CST), which teaches the more practical skills of medicine such as taking histories or doing patient examinations – this week, we are being introduced to the history taking process. But while it is exciting to learn what a doctor does, I can’t help but feel a different, uninspiring feeling rise up within me as I type. A twinge of… disappointment. The disappointment initially surprises me but after a while, it fades away. I soon realise why.  

When I was little, I thought doctors were a special breed of people – those blessed with levels of intellect, observation and analytical thinking far beyond that of the general population. A ‘superhuman’, if you’d like. I always marvelled how a GP, upon never seeing a patient before, could diagnose the cause of chest pain using a few questions, tests and some poking around and then prescribe the perfect drug, where the patient would then live happily ever after (hooray!). I imagined doctors had flashes of superhuman genius which told them what questions to ask, what diagnoses to make and what decisions to make in critical situations – a process mere humans could never understand.

But of course, doctors are human and have limitations like the rest of us. Doctors often get things wrong, with diagnostic error rates estimated to be close to an alarming 15% [1]. And from my first few weeks of medical school, it seems unlikely that wild ‘flashes of inspiration’ occur at all. Rather, medicine seems more mundane, more formulaic – a process of extracting the same pieces of information from each patient and recognising particular groups of symptoms. Almost like pattern recognition, like a game. Nothing too superhuman at all.

It’s somewhat disappointing to reach the conclusion that doctors probably aren’t too different from the rest of the population. I imagine the notion of the ‘superhuman doctor’ is something we hold for our own sake – we want doctors to be infallible, incapable of getting our diagnoses wrong, when in fact doctors can get sick, miss their families and become exhausted just like the rest of us. Despite all this, the ordinary doctor tries their best to repair a patient, knowing full well that they share the same limitations of energy, time and need for social connection.

But perhaps it is exactly this that makes doctors and other allied health workers superhuman: the constant exertion of effort to reach an unattainable level of perfection for the sake of the poor, the injured and the broken. It’s taking potential burnout, imposter syndrome and unmet social commitments and temporarily moving them aside to make space for the patient’s needs. Caring: perhaps this is what makes healthcare workers superhuman – not some transcendence of IQ or memory, but something more subtle, more internal: the prioritisation of others’ needs above your own. Now that is pretty extraordinary.

Sources:
1. Graber ML. The incidence of diagnostic error in medicine. BMJ Quality and Safety. 2013 Oct; 22(Suppl 2): ii21-ii27.

Three weeks have officially passed for my first year in the Doctor of Medicine (MD) at Melbourne University. According to older and more experienced students, MD1 is a precious time in the context of a medical career: you have the most time you’ll ever have, there are zero expectations of you and you’re only there to learn. Over the next few years, I’ll be documenting this journey ahead – everything from the bright and beautiful to the dark and demoralising, with this post marking the start. I don’t really have a plan of what I’ll be writing about, so here goes nothing.

INTRODUCTIONS

“Hey there, I’m Eric – what’s your name?”

Of the 359 students in MD1, most of the faces are new but there are some familiar ones. Through ice-breakers, orientation activities and lunch breaks, I’ve slowly begun to meet some of the new faces who I’ll be calling colleagues over the next few years, and catch up with old friends.

The act of mingling was draining in the first few weeks, but things are slowly settling down. Groups are beginning to form, with clusters in lectures and circles in lunch breaks taking shape. Without a doubt, getting to know new faces throughout the next few years is something I’m looking forward to.

Most people seem friendly and relaxed, making it easy to forget that many of these individuals are likely straight A students, accustomed to topping their classes and acing every exam. I wonder what will happen now that these students are now all together – how and if their expectations will shift throughout the years given the competitive nature of this course. On the other hand, not seeing faces who I’ve become accustomed to seeing during undergrad is a little strange; friends who have moved to different states, who have gone down different paths. But things like this happen, and I have faith they’ll do great things no matter where they’re placed.

RESILIENCE

Some of the themes of the first week of MD1 included resilience and developing a ‘growth mindset’ – stuff like if you ever fall, fall forward. Within these talks, the idea of imposter syndrome came up frequently as a reminder that yes, imposter syndrome happens to everyone and no, don’t listen to those thoughts – you absolutely deserve to be in this course.

There are many arguments that could be made against doing medicine. You are studying for a long time (essentially your whole life), you will probably experience some form of burnout in navigating patients and hospital systems, leading you to almost certainly work long hours whilst trying to maintain a healthy personal life. On top of that, you are in an inherently competitive field with a vast number of brilliant minds vying for a limited number of specialist positions, of which many exams stand along the way. It is no wonder imposter syndrome and burnout are such big problems in this field.

But of course, these are also reasons why one would decide to go into medicine. The thrill of lifelong learning, the opportunity to meet patients’ health needs as another human and the opportunity to work in a team of like-minded, capable individuals must surely be worth the inevitable struggle to receive these gifts or going to medical school would be nonsensical.

Things may change and I may drop out of med school in the future, but for now, I’m content on this path that God has placed me on.

February 2017

“Remember to call us, okay? And remember to eat eggs. Eggs are good for you.”

My mother studies my face hard and I smile back at her. A few weeks ago, I made the decision to accept my Bachelor of Biomedicine offer from Melbourne University. Since I grew up in Perth, this decision meant moving out to a city I’d never been to before, away from my family and the shelter I’d grown up in for 18 years. In my smile, I try to hide my nervousness for the uncertain road ahead, but I suspect mum sees past it.

“Of course, mum – I’ll see you in a few months. I love you.”

After a long hug, I wave my mother off as she departs back to Perth, leaving me behind in Melbourne for me to begin a new chapter: University.

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Present

That day marked the beginning of my Undergraduate journey, which quickly swept me off my feet. Juggling Biomed’s study load, adulthood, a reasonable social life and extra-curriculars was both exhilarating and exhausting, never seeming to stop. Having recently graduated, marking an official end to this whirlwind (until the next degree), it feels strange to draw the curtains on this chapter. As for all good things, I find it helpful to reflect briefly on the time that has passed, so here we go.

Like a long-winded anime, various ‘arcs’ were played out throughout the 3 years of my degree. These included the chaotic GAMSAT and medicine interview preparation arcs as well as the more structured semester arcs (upper limb anatomy, you still haunt my nightmares). Amazingly, I’ve realised that throughout every single arc, I’ve had the opportunity to meet brilliant and caring individuals who I somehow now have the privilege to call my friends. To the friends whose paths have aligned with mine and have shaped this chapter of Biomed, thank you. Whether you were with me in Immunology cram sessions, 400m repeats on the track, practicing GAMSAT essays or there in the background as a friendly face, you have added some magic to the great and terrible days and I am grateful for you all.

No doubt, Biomed brought along its fair share of challenges which forced me to adapt. These adaptations include appreciating the importance of sleep, listening to lectures at 2x speed and training my taste buds to tolerate my shockingly bland cooking. Writing also became an interesting adaptation for me and rapidly became an antidote to my more pronounced introversion. Though I haven’t really found a writing style, I’ve had fun jotting down random thoughts and experimenting with how to write them.

Biomed was also a harsh teacher and brought on challenges which I drastically failed, exposing my flaws in broad daylight. It is somewhat of a sad paradox that despite having graduated from supposedly one of the most competitive courses in Australia, I feel like I know even less than when I came in. Perhaps this illustrates a recognition of my profound arrogance coming out of high school, but there is no doubt in my mind about it now: this world we inhabit and these bodies we possess are amazing and I know so incredibly little about it all. As this chapter of Biomed draws to a close, I am excited to explore whole new worlds as the next chapter in Medicine slowly draws open its curtains.

As 2020 brings on new challenges and friendships for everyone, here’s to many more magical times filled with awe, wonder and laughter.

I’m sitting in a suit, facing a young Asian woman wearing black, round glasses across a desk. On the desk in front of her is an iPad, and she sits cross-legged, hands resting on her legs. I’m in my interview for medical school, and the woman across me, who introduced herself as Angela, is awaiting my response.

I pause and mentally check my body posture. Am I sitting straight? Am I smiling? Are my arms relaxed? I quickly remind myself of the script I’d practiced over and over again, and begin.

“Well, that’s a hard question. While medicine is incredibly rewarding, there are so many challenging facets to it. I’ll give two challenges which apply the most to me. Firstly: The work-life balance.”

I’m on a tight time limit: 5 minutes to answer 4 questions until the bell rings and I’m thrown into the next room, to another station. I quickly explain the foreseeable challenges of balancing large time commitments to patients and learning whilst having a normal social life. Angela looks bored. She’s no doubt heard this dialogue before.

“Another challenge which I see myself facing as a doctor is the emotional aspect of medicine.”

Angela raises an eyebrow, inviting me to explain what I mean.

“I imagine there will be times where I will come across patients in such a critical condition that I’m unable to help them, no matter how hard I try. In times like these, I worry that this inability to help will put an emotional toll on me, affecting my ability to work.”

A voice silently cries out at me as I talk.

Don’t lie Eric. What you fear isn’t caring too much, it’s caring too little. It’s the fear that one day, you’ll no longer see patients as people with lives and problems as complex as your own, but as obstacles waiting to be diagnosed – obstacles that can be dealt with by prescribing little pills. It’s the fear that you’ll no longer care and listen to patients who are scared and confused, but instead face their questions with apathy and frustration. It’s the fear that one day, your desire to help others will be quenched, replaced by an emotionless, robotic void that lacks empathy and seeks only to get patients in and out as fast as possible, forgetting that they too, are human, and require human connection as well as pharmacological treatment. No, the greatest challenge is to be able to help others regain their humanity, without the cost of your own.

“Is there anything else you’d like to add?”

Angela looks up at me two questions later, seeming pleased with my responses. I’d finished early.

Yes. Say it. The voice inside me begs. But I can’t. “No.” I say after some consideration, smiling at her. She smiles back. The bell rings a few seconds later. I thank her, open the door and leave, move to the next room and quiet down my inner voice.

A few weeks ago, I came across this slide from one of my Immunology lectures:

Thankfully, the point of the slide wasn’t to learn all these different cytokines (=small proteins that are important in cell signalling), but I remember staring at the table utterly stunned by all these different proteins within us and how unimaginably intricate our bodies are.

Sometimes, I feel a little overwhelmed by the complexity of life. How huge numbers of white blood cells are constantly circulating in us on the lookout for foreign molecules. How our cells are so finely orchestrated to secrete correctly folded proteins in just the right amount, at just the right time. How intricate cell signalling pathways are. How a tiny embryo grows into a being that can run, laugh, see, ruminate, cry and read. The more I study biomedicine and the more I uncover life’s complexity, the more I’m drawn to its allure. And even though I doubt I could ever grasp the true complexity of our bodies, it truly excites me to study it and learn more.

Some of these feelings are echoed in a song called “Saturn”. One of its lyrics I often wonder myself: ‘How rare and beautiful it is to even exist’.