Casual[Cruel]ty

I don’t like writing about medicine if I can help it (ya’ll have asked). But as I start preparing to rejoin the clinical fracas (death by a 1000 cuts) I would like to reflect on power: I think we have a profound misunderstanding of the amount of power we wield over one another as colleagues. The damage we do. I’m going to tell you a tale of casual cruelty that stuck with me longer than it had any right to. But it illustrates my point perfectly *minor details changed for obvious reasons*

Setting: pre-call handover [non-clinical folk: this is when the person taking over for the night gets a run-down of the patients in the unit from the day team. Patient status and vital information is exchanged here]. I’m trying to familiarise myself with the very sick patients that’ll be in my care for the next 18 or so hours.

Further context: I’m relatively new here (it’s maybe my 2nd month) and today I’ve been involved in an (overall successful) resuscitation effort on one patient for the past several hours. As such, I’m unfamiliar with all the other patients in the units today and did not get the handover from my colleagues. My senior on-call with me tonight (who is also here for the handover) seeing my situation, offered to take the handover from the day team and promised they’d pass the information on when walking through the patients with me.

Human: my senior, one of “the good ones”, likes to teach I’m told. Also “means well”, I guess.

Exchange:

Them: who is this patient?
Me: (mildly confused given *above context *) I don’t know, let me open the file and read the case to you so we can both know for tonight?
Them: *waits expectantly*
Me: *reads case, then turns to ask *was there anything they told you on handover that I needed to know in particular? Procedures? Results? Concerns?
Them: *waves dismissively* no.

*(rinse and repeat for about 4 or 5 patients. I’m baffled)*

Them: who is this patient?
Me: * increasingly frustrated and bewildered* I don’t know yet, let me read-
Them:* interrupts* you’re studying for Part Ones right [part ones are entry level specialist exams, they’re rigorous and require a great deal of studying, basic sciences and clinical application]
Me: Yes, I am.
Them: Let me quiz you
Me: * grateful for the volunteered help, baffled by the timing and setting * uhm…. O-OK.
Them: Tell me *[something] * about the foetal circulation
Me: * turns away from getting to know my patient and looks for scrap paper*
Them: what are you doing?
Me: looking for paper.
Them: why?
Me: because I’m going to draw it for you.
Them: you should know this off the top of your head
Me: it only makes sense to me when I draw it, that’s how it’s stored in my brain.
Them: no man, just tell me.
Me: I will, let me just quickly draw *starts sketching*
Them: what will you do in the exam?
Me: they give us paper in the exam.
Them: and in an interview?
Me: *puzzled * I’ll ask for paper.


this goes on for a bewildering amount of time. Why does it matter how I deliver the information?


Them:* demands* tell me without writing it down .
Me: *concedes because we’ve wasted so much time and I forget a step*
Them: (*predictably berates me*) you forgot this step.
Me: remains silent and glances at patient notes that I still haven’t read. It’s now 5pm. It’s been an hour and we’re only halfway through the patients


Them: *sees me doing this* right, let’s continue. Who is this patient?

*at the final patient, the incredibly sick one I’ve been busy with for hours *


Them: what’s your differential for the causes of PPHN?

Me: *lists about 4 or 5 common things*
Them: none of those apply to this baby
Me: yes, we’re not entirely sure what’s causing this in this infant yet. But the current suspicion is *[insert condition]*
Them: have you heard of *lists 2 or 3 additional rare conditions I’ve never actually encountered before, one of which might explain what’s happening to my patient.*
Me: *takes notes* no, but I’ll look them up. I also think one of those might explain this patient’s unusual presentation *[learning mind starts to get excited]*
Them: and how do we manage this?
Me: *again, lists 3 most common management courses*
Them: this doesn’t apply to this child.
Me: yes, I agree. We tried all 3 of the above and they didn’t work here.
Them: what about HFOV
Me: *I gasp*, I realise we DID briefly try that with near disastrous results*. I have to be honest, I’m not too familiar with using HFOV yet and therefore it didn’t even cross my mind as a management option. That’s genuinely a very real gap in my knowledge that I’m hoping to-
Them: * let’s out a derisive laugh*, “that’s the least of your gaps“.
Me: *dumbfounded*
Them: *unaware of the damage* what about ECMO?
Me:* quietly* I’ve never seen it done in State.
Them: it isn’t usually but it’s still part of management.
Me:… OK.

Context: it’s now approaching 6pm. I haven’t started any of my patient reviews, blood gasses or procedures. This is the person I’ll have to call in less than 3 hours with detailed updates on all of these patients. This is the person I’ll have to call tonight if I’m uncertain or get stuck.

Debrief

I’ll never forget it. This exchange changed me for a very long time: I was always filled with dread after that. I felt unsafe to ask or answer questions lest I accidentally reveal more “gaps” (because the culture was to discuss us behind our backs first). I was studying and adjusting to the steep learning curve with gusto (my journal entries around this time were “yoh I’m seeing flames but I’M LEARNING SO MUCH!”). I’m excited by learning, I’m annoyingly inquisitive actually. My baseline is bubbly, I can be shockingly oblivious at times but have no tolerance for things that don’t make sense. I’m not one of God’s strongest soldiers and I don’t have low self-esteem (I’m fully aware that I’m also not everyone’s cup of tea either).

I wish I could tell you I was a badass about all of this, that I was an imbokotho and it was just water off a duck’s back or whatever. But it wasn’t: When I got home post-call, I. wept. For hours. I rarely weep (I’ve wept 5 times in living memory). And while I did eventually adress this (the person didn’t recall it at all) and I got what might be termed an apology, I was genuinely never the same. I recognise that this doesn’t even crack the top 500 list of meanest things that have ever happened to me (not even close). I cannot for the life of me understand how this one casual cruel comment slipped under my skin and had such a profound impact on me when so much worse has rolled off. Its unusual. Maybe it’s because it was so unexpected and unprovoked. I was so shaken that I considered sending an email to the HoD to ask for a formal evaluation of my work performance seeing as I clearly had some laughably obvious deficiencies. I can own the fact that I may be an oversensitive marshmallow who needs to express order some thick skin and a pair of BigGirlPanties. I am resigned to the knowledge that I have met crueller people and will meet many who are crueller still on this long path I’m treading. While I ascribe no malicious intent to the comment, it was, at best, unkind and I know I didn’t deserve it and therefore no longer accept it (I’m fine now BTW).

All I’m saying is this: we have to survive so many potentially traumatic things in our line of work as it is. Do we have to include each other to the list of “things to survive”? We’ve created so many cultures of casual cruelty amongst ourselves already that I think it’s time to start dismantling a few. I’m saying that we do real damage to each other in our callousness. People don’t seem to always understand their power. Understand your power clinicians.

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