Family time…something I won’t be enjoying this festive season… 😦

Not Not-So-Festive Season

This year will be my first year working over the festive season. People tend to forget–unless they get injured or ill–that hospitals don’t close over weekends and holidays, so doctors, nurses and skeleton staff don’t exactly get “Christmas holidays”. In fact, my intern group got a very stern notice reminding us that all unused leave had best be gobbled up before December first or be forfeit, because interns in particular carry the brunt of the workload over this time of year when most other departments scale down and shift to skeleton staff.

So I’m working (on call and in Casualty) Christmas weekend and New Year’s Day. This may sound less depressing since I don’t celebrate Christmas and I’m not a fan on New Year’s, but consider the fact that these are the busiest weekends of the year, our call roster shifts have doubled for the month of December, and most of the idiocy we deal with in Casualty (read: drunk people making stupid, dangerous choices that we must then try to remedy) typically triples over the average long weekend. That’s when people haven’t received bonuses that will facililitate increased investing increased drunkenness and poor decision-making. Also, with the other departments being on skeleton crew status, most traffic redirects to Casualty (read: flu. We have to treat the flu in our Emergency Department. This is not a drill.) and so the workload will invariably quadruple at minimum.

Now I’m a lazy gal, but not when it comes to my work. I take great pride in the work we do in the ED and I’m very serious about not assuming something that looks benign and flu-like is not really something more serious and potentially life-threatening like meningitis. I examine my patients fully, and investigate them appropriately, before sending them home with a very serious lecture about the purpose of the Emergency Department.*

That being said, I’d prefer not to be in the ED at all this time of year. The best workdays are short ones, and the best weekends are long ones. This is a universal truth. Even if I lack the holiday spirit, I still have a grandmother who cried when she realised this would be a Christmas spent without most of her adult children and grandchildren, especially her favourite one.** I’d much rather be with her than in a chaotic casualty, no matter how much of a high I get off of the work I do.

Mandatory Overtime and Burnout

Being an intern has several legal drawbacks. Some are there for our (and our patients’) protection, like the fact that we are supposed to be doing supervised work.

Excuse me for a second while I pretend to be coughing instead of laughing because the supervision in non-academic hospitals is a myth…

Woo, much better.

Another drawback exists because of our currently ridiculous inequality in South African health care. 80% of medical practitioners work in the private sector in South Africa serving 20% of the population, while 20% of us are in public serving the remaining 80%. This is one of the stark reminders that although we have internet access and Apple Stores, our country is still majority impoverished and we are really just a glossed-up version of the Third World. What this means for intern doctors (and Community Service doctors if I’m not mistaken?) is that overtime work is not something that is optional or negotiable. Our contracts are very clear: we have to work a certain quota of mandatory commuted overtime and will be expected to work more (unpaid) if there is a need as we form part of essential services. What this translates to, on a regular day, is exhausted, emotional and psychologically unstable junior doctors who lack clarity of mind to make the best decisions when it matters most and lack the emotional bandwidth to be sympathetic when people present for situations that really require a more human touch.

For context:

Now, I’m not naive. I know patients don’t really care how tired their doctor is. I’ve had several instances of personal experience where nonemergent patients who had seen us working non-stop from the time they’d arrived, had heckled and physically threatened any doctor that had stepped out for a quick thirty minute nap or bathroom break or supper break because of how ‘unfair’ it was that the doctor got to take a break while they had to wait. They didn’t care when the nurses had explained how long that particular doctor had already worked, they just cared that they’d been waiting x-hours and hadn’t been helped. There’s a colour-coded wristband campaign ongoing in the country where patients can choose not to be seen by a doctor with a red wristband (ie has worked longer then the maximum safe working quota and is the equivalent of a drunk person treating them) and patients have poo-poo’d the option because being seen by anyone was better than waiting fifteen more minutes for the next doctor to be available. I also know government doesn’t care–there is a shortage of doctors and a burdened healthcare system, they are going to exploit this vulnerable group for as long as they legally can and no change.org petition is going to sway them, even if it wins in the court of public opinion.

I have hope things will change, but nobody really feels bad for doctors (I mean our work is so glamorous!) so it won’t be soon and it won’t be enough.

Going to Australia, Mary!

One of my favourite bits of comedy by Trevor Noah, is the bit where he digs into the perpetual cycle of people threatening to leave South Africa because of political ‘turmoil’. Here’s an excerpt:

What’s super interesting is that, if you walk into the doctor’s lounge where the anaesthetists gather between cases, there’s a similar rhetoric. Not just with regards to politics, but also with regards to the increasingly deteriorating working conditions and the evergrowing disregard for the fact that doctors are humans entitled to (gasp!) human rights and humane working conditions. It’s an irony of immense proportions that the aneasthetists have these rants while sitting on plush couches drinking Jacobs Kronung brand coffee, but let’s suspend that imagery for a second and contemplate.

One senior medical officer (MO) complains chronically about call and call rosters. I was a little more than confused by this because, as far as I know, if you’re no longer a community service officer (CSO) or an intern, you don’t have to take call. As a matter of fact, all you have to do is tick a box at HR notifying them that you no longer will be working overtime. The catch? You no longer get compensated for overtime. Now if you’re a newly minted MO, maybe that’s a drastic cut. It’s over a third of your compensation (but even without it, your basic salary is more than you earned as a CSO, but let’s play devil’s advocate) and you have stuff to buy. But after years of working with no clear plan to specialise and thus increase your pay grade, surely you’ve bought the majority of stuff you want and need? Surely you can afford to say goodbye to the part of your worklife that sucks your soul dry and wreaks havoc with your physical and mental health? Surely you aren’t spending every cent of your paychecks in the naive hope that those paychecks will last forever and ever amen?

Or nah?

For the typical public service doctor, something fairly obvious hasn’t clicked. We trade shifts like commodities, exchanging time for money in the most tangible and obvious way. I’m on call the weekend of my sister’s wedding? No problem, Dr Ndlovu is willing to work that shift for R1500. I’ve just bought a day back of my time with money. I’m strapped for cash for a wedding gift? No biggie, Dr Vrede is looking for someone to work his shift this Friday. I’ve just sold a day of my time for money. I won’t even speak about the locum tenens transactions, since they are illegal during internship and I’m not sure how people sleep at night doing them. The gyst of it is, most doctors I work with already know that (over)time and money are interchangeable in our line of work (and, truly, in most lines of work). If you want to own more of your time, you either accept less compensation (post-CSO) or pay someone else to give up their time. Yet, that’s where the awareness stops. Few take it further and realise that, if they don’t spend all their money, they can actually eventually have control of their time all the time.

Exit Strategies

I’m not planning on moving to Australia in three years. I’m not planning on quitting medicine tomorrow. I have no interest in working in the private sector ever. But I’m also not planning on taking call forever.

The usual route I’ve seen people take, if they’re at all interested in solutions beyond just complaining, is to work really hard for the first few decades out of university and then, when they are either financially independent or simply able to live well on the basic salary, drop call. This is attractive if you’re planning to only drop overtime work as a gateway to traditional retirement at 65–most MO’s over 60 still work overtime where I work, and do a crappy job of it not so much because of age, but more because they stopped caring years before.

I’m (un)fortunately not planning on sacrificing myself on the alter of an inefficient public sector for the next forty years. I have things to do, goals to achieve and a full non-sleep-deprived life to live. This may sound selfish, but I think we’ve already established that nobody else cares about the workload junior doctors face and how this jades us, so I don’t feel an iota of guilt. Someone has to look out for me, and since it won’t be the public and it won’t be my employer (the government), it’s got to be me. I’ve decided to start considering the options I could have to structure a work-life balance that will take my health and well-being into account:

1. Work full-time, including overtime, until age 65. Save the minimum required to then retire at that age, hopefully sane and healthy enough to enjoy a few years of peace before I die.

2. Work full-time, including overtime, for the next 10 years, then drop overtime work until formal retirement. Save enough to be financially secure to accept lower compensation without overtime pay, without derailing my life goals and significantly dropping my standard of living. Then retire at 55, likely sane and healthy enough to enjoy a few years of peace before I die.

3. Work full-time, including overtime, until the end of ComServe while saving enough to be financially secure to then drop overtime work once it is no longer mandatory. Work for a total of ten years, saving aggressively enough to be financially independent, then have the option to either retire to something else, or continue part-time, or volunteer, or spend the rest of my life creating art, or doing nothing at all (unlikely).

4. Work full-time, including overtime, and illegal locum tenens work until the end of ComServe. Then continue working full-time, overtime,  and now-legal locums until financially independent at an accellerated thresshold. Then say dueces to working after barely six years out of university.

The elephant in the room, of course, is what would happen if I wanted to specialise? I have a burning passion for three fields with grueling registrar programmes that have a minimum of four years each. Registrars have to take call, and that is the one unattractive feature of becoming a specialist, although you can drop call again once you’re a Consultant. Option 2 works well in this case, but I don’t know if I can do this sleep-deprivation thing for another ten years. Option 3 eliminates specialising as an option for me, although I could still be an MO in these departments and fulfill my passions in that way. Option 3 also buys me a lot more time to build and develop my various non-medical interests fully enough to be able to easily transition if that’s what I choose to do, or to at least realise before I pull the plug that I’m better off in medicine. Options 1 and 4 make my teeth hurt.

It’s Not About The Money, Money, Money

I have a colleague (an intern) who has a goal of keeping her bank balance above R100 000 (in a cheque account!) for no reason other than that she likes the number. I think this is ridiculous because of the opportunity cost of that money not earning her any interest or growth, but she values having the option of unlimited discretionary funds so that motivates her to spend a little less than she otherwise would in the present.

My view is that money is infinite–there’s always someone willing to pay you to do something they cannot or would rather not do. Time on the other hand is not infinite. All of us are going to die. Some of us are going to get really ill. Some of us are going to no longer be able to pursue our non-work interests when we’re eventually old enough or redundant enough to get benched. Then what? You can’t buy back the time, and you can’t make more.

Discretionary money is great, but discretionary time is what I value.

If I can leverage the former to buy me more of the latter, all the better. If I can put myself in a position where I no longer have to sacrifice sleep and healthy eating patterns and bathroom breaks, where I no longer have to waste time in bureaucratic meetings where nothing of interest or depth is said or where people disrespect my time by being late or going overtime (uuuurggghh!), where I can afford to dedicate time to things that matter to me or even things that people tell me shouldn’t matter because of what I do for a living…why on earth not do that? I’m incredibly privileged to be making money doing a job I love (for now) and I feel that it would be irresponsible to not convert that privilege into power to give Future Me some options…

…but I’m also looking to give my future patients a less jaded, less burnt out, less cold doctor who won’t snap at them for faking seizures to get out of a domestic dispute. *** Because at my current exhaustion levels the snapping is unavoidable, and the regret is minimal.

*Some people don’t like that I lecture patients, especially since I’m younger than most of them. Maybe the word lecture is strong, but I don’t particularly care about the age differential. Health education is health education, and it’s part of my training to give it where it’s needed. A fourteen year old having her period for the first time, negative pregnancy test, presents with abdominal cramping and lower backache. Abdomen is not acute, x-rays are clear, vitals are stable and bloods are NAD. You best believe I’m going to give her the “These are period-pains” talk and then call her mother in to remind her what period pains are as well. Every hour we spend managing her monthly period pains instead of seeing a stab chest patient is an hour someone could die. I don’t play those games.

**Ssh…don’t tell my siblings.

***True story. As told by a patient in a really bad social situation who thought a night in hospital would soften their partner’s heart towards them. Sad, but very frustrating considering the volume of patients with actual medical emergencies who would truly need that bed. It’s a tough balance outchea.


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