As this issue looks into the mental health of medical doctors and students,SMA New hears from three doctors who considered leaving the profession amid the challenges medical practice has brought upon their respective mental states.
I almost didn't do medicine when... I got diagnosed with leukaemia before I even graduated from primary school.
I held on only because... I got better with new chemotherapy drugs, caring nurses and a great doctor.
I almost didn't do medicine when... my junior college (JC) principal said that those who did not take Biology at the GCE O Level should go to her office, if they dared to try.
I held on only because... after spending two-and-a-half years of my "post-terminal" life as an administrative assistant, the National University of Singapore opened up applications to students who took only Chemistry.
I thought of quitting medicine when... I failed the MBBS and had to see my classmates become house officers (HOs) ahead of me.
I held on because... the group of us left behind banded together and the camaraderie kept us going.
I thought of quitting medicine when... I went post call at 11 pm and I only managed a one-hour nap by skipping meals.
I held on only because... my other HO was there to clear the changes and cover me while I napped.
I thought of quitting medicine when... I was febrile and had to struggle through work in the day because there was no cover, but didn't dare to go on-call because I was afraid of passing what bug I had to my on-call oncology patients.
I held on only because... the on-call medical officer (MO) gave a very gentle and resigned "okay" and covered the call by himself.
I thought of quitting medicine when... I almost killed a patient by messing up a group and cross match for a patient I had never seen, amid a mountain of other changes.
I held on only because... the nurses caught the mistake and showed me empathy.
I thought of quitting medicine when... I probably killed a patient after discharging them too early. ("Dear colleagues, the bed occupancy rate is 110%. Kindly expedite discharges.") The patient was re-admitted for deep vein thrombosis complicated by a pulmonary embolism because we didn't mobilise her prior to discharge. She collapsed in front of us during rounds.
I held on only because... kind registrars and MOs helped in the resuscitation and my loved ones supported me.
All those above happened even before becoming a full-fledged doctor! Perhaps the worst was over?
I thought of quitting medicine when... as a medical officer in my first posting I almost missed a hepatocellular carcinoma while rushing through a busy 70-90 patient per day walk-in clinic.
I held on only because... fortunately, someone else saved me from my mistake by picking up the hepatomegaly and referring the patient for further care.
I thought of quitting medicine when... my girlfriend didn't understand why I was exhausted and needed to sleep after Saturday morning clinics. "Everyone else who works five-and-a-half days does not need to nap on Saturday afternoons, why do you need to?"
I held on only because... I eventually figured out that I needed a more supportive partner.
I thought of quitting medicine when... I saw my former secondary school and JC classmates (who did worse than me in school) succeeding in life and buying property, while I struggled to repay my college tuition fee loans.
I held on only because... "I am in blood / Stepped in so far that, should I wade no more, / Returning were as tedious as go o'er" (Macbeth, Shakespeare, Act 3 Scene 4, 142-144)
Fast forward to today...
I think of quitting medicine when... people say Singapore's healthcare system is one of the best in the world because of how little of our gross domestic product per capita we spend on it.
I think of quitting medicine when... people clap for frontliners but don't really care to ask how they are doing.
I think of quitting medicine when... people would rather take deworming medicine than trust their doctor's advice on which vaccine to take.
I think of quitting medicine when... what we are told to do does not sync with the reality of caring for patients on the ground.
I think of quitting medicine when... people tell me I deserve better.
I hold on only because...
Mostly, I am too tired to learn new skills and change my occupation, and medicine pays the bills. I have hope however, that the people in power will truly learn not pride of knowledge, but humility of wisdom.
They say medicine is a calling, not an occupation. Yet, now it feels like a preoccupation, a culling of sorts.
To my stronger and more competent colleagues, I will not clap for you. I will not encourage you to fight the good fight. Instead, let me silently nod and remind you that if you ever are in a position of power, think of the rest of us. Make not just medicine, but society as a whole a better place.
Medicine has been my life for years. I thought I'd seen it all and could endure much. I thought I was strong, independent and a protector.
I did not expect a simple thing like a nasal swab to take me down.
When the rostered routine testing (RRT) began, I was confident I would get through the eight scheduled swabs and that would be the end of it. With some bravado and humour, my friends and I proudly proclaimed that we would get through the "nose cleaning" procedure.
There were funny memes about it too, laughs all around.
But after the first two sessions of compulsory deep nasal swabs, which would be processed by polymerase chain reaction, I began to develop niggling pain with traces of blood after each swab. My fear of the procedure grew. I began to feel like it was drilling into the back of my head. It was traumatising.
I thought I was going crazy. I thought I was the only one. People downplayed how I felt, and made me feel like I was overreacting. I'm almost ashamed to say that I needed to see a psychiatrist for help – but I am glad I did.
I couldn't endure another deep nasal swab; so, I stopped inpatient work. My income took a hit, but I figured I needed to put my mental health first. In the back of my mind, though, was this thought: if this continues, I might leave the profession entirely – over a deep nasal swab.
Thankfully, my institution has now modified the RRT process to something acceptable for me.
What is medicine? – A passion? A lifelong pursuit? A love? A duty? A jealous mistress?
It is no accident that all of the above invoke the imagery of a human relationship. The calling, the training and the dedication to medicine more closely resemble the commitment of a marriage than a 9-to-5 job.
And that is as it should be, shouldn't it? However, if medicine is a marriage, when is the relationship an abusive one?
As a medical student, Google taught me almost everything I knew, so I asked Google once again. Dr John Gottman of the Gottman Institute defines the ten signs of emotional abuse as such:
- Control. Do you find that medicine controls when you eat and sleep, what events you can go to, (and most recently during this pandemic) who you can eat with, both during and after work hours? Check.
- Yelling. Have you been yelled at as a house officer/junior doctor? Frequently? No? I have a piece of land on Mars to sell to you. Check.
- Contempt. "All of you together can get an MBBS distinction, but each one of you would fail miserably." Sound familiar? Check.
- Excessive defensiveness. Having to defend your every move and clinical decision. Yes, that's emotional abuse. Check.
- Threats. "If you quit, you'll have to pay back the $500,000 bond to us." Check.
- Stonewalling. Tried having salary negotiations with hospital human resource departments or discussing your future training prospects with your consultant/residency director? Ever got a decent response? Check.
- Blame. If you don't think this happens, you've clearly never sat in a hospital morbidity and mortality round. Check.
- Gaslighting. Are your concerns frequently dismissed? Do you find yourself doubting your opinion, memories and even sanity frequently? Check.
- Isolation. Working 100 hours a week is pretty isolating. Check.
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Volatility. Does "The highs are very high and the lows are very low" sound familiar? Sounds like a career in medicine? Check.
Google then goes on to say that if you check all ten, you should run as far from that relationship as possible. Did I run? Well, almost.
One fine day after a particularly abusive posting with some particularly abusive senior doctors, I took a particularly long leave of absence and seriously considered my options. Part of the leave period was no-pay leave, while the remaining was leave that I had not managed to claim and had accumulated for two years.
For four months, I rested and slept. Exercised. Breathed in the morning air and felt the night dew. I had finished serving my bond. The threats did not work anymore. The control, yelling, contempt, gaslighting, stonewalling and blame washed over and through me. I looked past it.
Perhaps if something had offered itself up, I might have moved on, but nothing did. After the prolonged rest, I returned to medicine; but I never loved her the same way again, because loving someone gives them power over you, and I resolved never to let medicine have that power over me again.
"The moment the slave resolves that he will no longer be a slave, his fetters fall. He frees himself and shows the way to others. Freedom and slavery are mental states!" – Mahatma Gandhi