My first year of internship is officially over.
I can’t believe I just typed that. It seems so surreal that just a over a year ago, I was making my way
downtown up to this rural township, contemplating how I would navigate a year out in the sticks, doing Real Grown Up Medicine with limited resources in a community whose language I’m not fluent in. I had all these idealistic ideas about how I would approach each challenge, and how this would build me up for the years of service I’d promised myself I would practice in the Public Health Sector. I was going to be the most compassionate, most dedicated, most optimistic doctor my patients had ever had. I was going to be the change I wanted to see in the system, because the system was fixable, it just needed buy-in from those of us who make it up.
Man was I naive.
I still believe I can make a difference–I believe every junior doctor who enters the system can–but I’m no longer an outsider looking in, haughtily nitpicking at what I see with the confidence of the ignorant. I know now why the system won’t work, even if it can. I’ve experienced the harsh realities of trying to practice medicine using first world standards (the standards we are litigated against) while only having third world resources. I no longer judge my colleagues who flee to the relative safety of private practice (unless they write us crappy referral letters, then I judge harshly!) because I’ve realised something I should have realised as a medical student during student internship.
The Public Sector doesn’t value us.
I’ve had enough conversations with bureaucrats, administrators and patients alike to know that doctors, especially junior doctors, who serve in public are not actually considered important enough to be listened to. Oh, sure, we have a mostly steady income stream, but that’s actually the problem. People think that because we get paid, we need to shut up and swallow any abuse that gets hurled our way. Never mind that what we have to say may have value and may help alleviate inefficiencies in the system. If we aren’t working, we don’t exist.
Take for example the junior intern who painstakingly assesses every patient, fully examining each system and excluding every differential until he becomes confident enough to start expediting his consultations. As soon as he makes his first mistake, the hornets are on him. Department Heads ridicule his clinical acumen and seniors label him incompetent and unsafe. Never mind that he is probably safer than most of his peers who do the bare minimum–he’s not a person, and certainly not one of any importance, so context is irrelevant. Nobody ever calls him in, sits him down, walks him through his errors. Instead he is slandered and maligned until he decides that he too is going to start doing mediocre work with notes so scanty you’ll never be able to critique them.
This may sound like a purely hypothetical case, but I’ve seen it happen to three of the best interns I’ve ever worked with. Mediocrity is accepted, excellence is overlooked, and people just cannot wait for an opportunity to humble an otherwise excellent doctor who makes the occasional error, while letting their less focused (often less safe) peers carry on completely oblivious.
Or let’s discuss the Remuneration of Work Outside of the Public Sector, otherwise known as RWOPS. It’s no secret that superspecialised (or simply specialised) doctors make more in private. It’s also no secret that juniors get trained in public. In order for the system not to collapse under the strain of undertrained doctors, we need the specialists to come to public. Are they incentivised to do so? No. In fact, they are penalised via RWOPS. They are told, “serve the community, train the young minds, get a few payroll perks, but minimize how often you consult or work outside the state sector. We’re watching.” So they leave so that they can reclaim their autonomy. Clearly, the public sector doesn’t need them that much if they are going to be penalised for entrepreneurship and ambition.
Let’s look at the placement processes. Internship was extended to two years to keep the pool of doctors in the public sector for longer. Community Service (or ComServe) year was introduced to further extend that. You cannot qualify for independent practice in South Africa without having completed these three years so without them your degree is essentially just a piece of paper. For all the effort the government throws into forcing us to work in the public sector for an additional three years, you’d think they’d ensure the jobs are there. Yet more and more, placements end with doctors being unemployed for months on end, with no fire underneath the bureaucrats to correct these grievous errors. I got my job months after I should have, with nothing more than a phone-call about “lost applications” and a thinly veiled threat that there were no other options if I turned this one down. Two friends of mine sat unemployed for months because posts were “frozen”–but little came in the way of communication as to what to expect. In any other industry, you could just go to the competition and get a job if you had the experience and qualifications. In South Africa’s health system, there is no competition because of the mandatory community service. You simply can’t work for anyone else for three years. You are at the mercy of the government to decide whether you matter enough to get a straight answer. And because you don’t (matter) how you feed your family in the interim is none of their concern.
Or let’s take this closer to home. Safe Working Hours. Pilots are given very strict rules about how many consecutive hours they can fly, and how often they should take rest days. They have the lives of hundreds of people in their hands–they need to be well-rested and clear minded to avoid deadly mistakes. Pilots are paid well, too, but nobody says to them, “For the amount of money you get paid, you’d better work ungodly hours under unsafe conditions. Shut up and earn your salary.” Why? Because anyone with half a brain cell knows it’s in the best interests of the passengers that the pilot isn’t exhausted or burnt out.
Internationally, a number of Safe Working Hours campaigns have been springing into existence. On home soil, medical students and doctors across the country have been championing the rights of junior doctors to have humane working conditions–including reasonable shift lengths, enforced breaks and post-calls. It’s still in its infancy, but the public outcry has been truly disturbing. Except for those times when doctors die in car accidents after falling asleep behind the wheel while driving home from calls, we get zero empathy. (Note: we have to die before people remember we are human.) We are being called whiny and entitled, people are brandishing our salaries at us and asking why we can’t just be satisfied with being well-reimbursed (haha, funny!) and shut up and do the work. Work that requires us to make life and death decisions. Work that requires soberness of mind and clarity of judgement. People want us to do that work on three hours of sleep with a twenty four hour shift pending. And when patients die, when things go wrong, it’s incompetence that’s to blame. Never fatigue. Never exhaustion. Never basic human rights violations.
(As an aside, I never thought I’d relate to a Rihanna song (or link one to medicine!) but when she sings in that lazy, tired, resigned tone about how “I wake up and act like nothing’s wrong, just get ready for work, work, work, work, work, work” and how “it’s in me, do me dirt, dirt,dirt, dirt, dirt, dirt” as in it’s ingrained in her to accept mistreatment despite the fact that “you know I dealt with you the nicest” , I gotta say, I get teary eyed.
You’re welcome for this new interpretation.)
So you go to work, work that is otherwise fulfilling and satisfying, but you can’t bring yourself to feel any of that. Instead you feel anger and irritation. All your best intentions are dulled by your sense of complete powerlessness. You want to be patient and attentive to your patients, but your patience and attention died about sixteen hours into your latest shift. You want to go the extra mile, above and beyond, stay after hours and longer to explain conditions to relatives, but the only part of your life that you have any control over is your after-hours time, and you can’t bring yourself to give that away too. You want to stay in public, to serve, to elevate, to inspire a new generation to shake things up…but you’re only human. You also have needs. Emotional, psychological, physical needs that grow more urgent with each passing day in this mess of a state health sector.
So you run.
And then they complain. You get called selfish, greedy, unpatriotic. They make new laws and policies that aim to outlaw private practice entirely. They don’t value us while we are here, then they cry out when we finally have the agency to make choices that will help us build the lives and careers we envisioned. It’s not about the money–anyone who studied medicine could have earned a lot more for a lot less effort and heartache in a different industry. It’s about the culture against people who want to serve–and people mistaking that with us being slaves.