Sawicki is based in Wellington central. Photo / Mark Mitchell
Seeing shattered lives, putting targets in the way of patient care and extreme emotional and physical fatigue.
That is just some of what Kiwi doctors go through, says Wellington GP Nina Sawicki.
The mother-of-three is one of several New Zealand doctors featured in a new book, Beyond the Stethoscope.
It comes as junior doctors await recommendations from the Employment Relations Authority after mediation between the Resident Doctors Association and DHBs over contract negotiations.
As well as caring for patients going through chaotic lives, Sawicki has experienced her share of heart-break. Her mother committed suicide, and her son is profoundly deaf.
The doctor, based at the City Medical Centre on Lambton Quay, shares her story in the extract below.
Let's start by talking honestly about what being a doctor is really like. What it's like
on a day-to-day basis in terms of how it impacts on you – there's physical fatigue, there's psychological fatigue and there's also a deeper, kind of spiritual fatigue.
Is it reasonable to ask one human being to see so much pain in a structured job which doesn't actually allow you to even acknowledge that the pain is there, because you've got to make diagnoses, write scripts, have performance indicators and stay at arm's-length? We're not going to get anywhere unless we get doctors together to really talk.
There are expectations of what are good outputs in medicine – they are things like getting your screening rate up, immunising children, and getting diabetics on the drugs that the research tells us they'll do better on. I don't think anyone's got any issues with measuring a doctor's performance in this way, but it's all become so driven, as if there is a standard recipe for everyone and every condition.
But the fact that there is a human being somewhere in that recipe who is cooking – no one is talking about that. So the person may have a better life if they take this drug, but they may have good reasons not to want to take it, and it is not our job to force it on them. It is our job to develop a relationship so that they can come to us with trust. I just see so many tensions bouncing around in there.
In a well-educated, literate, unharmed, undamaged population, the outputs model of medicine is much more achievable. But not when you're dealing with the sorts of people who I see, who have been abandoned, neglected or abused by their parents; many of whom have chronic conditions. We call some of these illnesses 'acceptable illnesses,' but our behaviour doesn't represent that. We treat them as if they are somehow being naughty, and need to pull their socks up. I think that is really the attitude of the medical profession towards these people – nobody really wants to look after them.
Often the people I see have led incredibly broken lives. I have seen the Third World in Wellington. I kind of knew it existed but that was only intellectual. I see people whose lives are shattered. For example, last week I saw a woman who was 47. She was a heavy smoker – she came in drunk, and she looked like she was closer to 70. She had lost a partner through murder but it had never been taken through the justice system, for a number of reasons. She'd been diagnosed with severe emphysema – she had about a quarter of her lung function. I raised the issue of smoking because it is never too late, but she looked me in the eye and said: "Well, I'm dying – you know – I'm dying, what the f***?" Where do you start your smoking cessation programme?
Do I put in the task bar: "I've done smoking education, I've done motivational support, discussed prescription drugs?" I would have ticked all the little boxes that the auditors from the government like to see that we've ticked to show that we are good GPs. But, I'm listening to a woman whose lungs, and probably her soul, are a third of what they could be. People like her need care more than the people who will eventually stop smoking, who will use the patches – for whom we can tick all the boxes. That's not all that hard, but these people we see here – they are so broken that just trying to develop a relationship with them is a mission in its own right.
Until you've got that relationship, how can you expect them to listen to what you say? And you can't have a relationship with them, I believe, unless the patient believes that you understand their pain, or their past. There's nowhere to move – if you don't have that, it's all hot air. The people here are often suffering through circumstances which are beyond their control. Even if they were to blame, you can't judge people for the source of their pain. I don't know how sustainable doing this kind of work is.
I've seen three people this morning so far. The first had nursed a partner with prostate cancer at forty-five; she'd been sexually abused; she had someone crowbarred on her lawn a month earlier – she's in protective housing as a victim of domestic violence so she's been relocated to this area with some unsavoury characters around her – she had a paedophile across her lawn; she's got children at home; she's looking after her aunty who was a victim of the Christchurch earthquake, and she's come to me today because she's realised that maybe she's depressed!
You don't want to think: Yep, what's the next drama? Once you get like that, you shouldn't be in the job. But how can you see patient, after patient like this? The next patient was a young man of thirty-five, had been unemployed for eighteen months; both parents are dead; no partner, no children; maybe a couple of friends. He has Asperger's syndrome so science tells us he's going to have some challenges. He asked for help; help didn't come. He got too stressed at work so gave it up. He smokes a bit of cannabis. You don't have to know much about medicine and health to know that his future's not looking rosy.
Human pain, human suffering and human misery have to be married with medicine and science. Having the science isn't enough, and having a heart isn't enough – you somehow have to marry the two.
You can see maybe one or two people a day like that but because this clinic has been set up to look after people that others won't look after. We see them day in and day out. I don't know what the answer is.
I don't think the funders, the policy makers and the medical trainers – who tend to be academics who have gone through hospital hierarchy – get it. It's almost like the elephant in the room; people can see it but they're not talking about it.
If you name something, it loses a lot of power and fear. Sometimes we imagine that something is worse than it actually is if we ask or find out more about it. I remember reading that opiate use in older Australians is going up. Australia is one of the wealthier nations in the world and has got one of the highest standards of living. I don't know what is going on there, but the abuse of drugs is not getting to be less of a problem, so what is sitting there is maybe a blend of biology, susceptibility and hurt.
Why would you use drugs that destroy you if you're not hurting? I work part-time in a very high-income practice three mornings a week, which is an interesting contrast. When I came and worked here, I was starting to feel tired of wealthy parents bringing their children in with a sore throat, or "they've been a bit faint, could you do an eye test," or "I need to be back at work because I've got an important meeting and you're making me late for it." I just felt – this is not real.
I suppose a couple of personal things have had an impact on why I became a doctor, and perhaps why I work in this environment. My father was a holocaust survivor: he went to Siberia as a young man and survived it as a bit of luck, but was totally bereft – he lost his immediate family, everything.
He was eventually reunited with the remaining part of his family in another country, but was completely dislocated. I guess I kind of know that you can live through seeing a lot of trauma and you just get through it, you just keep going. A driving issue for him was that we had a duty to do something worthwhile with our lives. When I expressed, at about sixteen, that I might like to be a doctor, his comment was: "You'd never be able to doubt what you've done with your life." That counts for a lot.
You can make money, become famous, have a nice life, but actually doing something worthwhile matters.
My mother had very severe mental illness. She had very severe and frequent bouts of depression and she eventually suicided. She had many attempts in her life. I kind of sensed that somehow the system failed her. Admittedly psychiatric care has improved because we've got better science and better drugs; but the system didn't serve her in a lot of other very basic ways that didn't have anything to do with drugs. They had to do with bringing things out in the open and supporting her rather than incarcerating her, and thinking about what it all meant for her family.
Although this all sounds negative, I'm actually a positive person. I actually think most people want to do good, but circumstances may have not enabled them to. I sustain myself with mountaineering. I've always loved the outdoors and my husband and I have done a lot of tramping.
We've got two daughters, then a seven-year gap, and our son. He's profoundly deaf; he's got a double bionic ear. I had a pretty rough time when he was little because cochlear implants were still untested; there were ethical issues and technical issues. Anyway, he was implanted and when I wasn't working I pretty much devoted my time to giving him language. He's on his way now; he's on his journey. He speaks well, but he's got issues to deal with.
Being a teenager and being deaf and not being sports mad is not an easy place to be for a boy in New Zealand. He's a pretty grounded kid; he's starting to withdraw a bit from me. So now it is time that I can do a bit more for myself.
My husband suggested I do a mountain skills course and I fell in love with it. Getting into the alpine environment, into the wilderness and concentrating on food, shelter and warmth – the basics – is very grounding. If you're warm, sheltered, and your belly's full, life's pretty sweet.
I'm also fed by just the incredible physical beauty and the amazing supportive, encouraging people I've met. I've often wanted to write, but at the moment it's not really an option. Maybe at the age of 60 I'll get my pen out!
A lot of people have written about the psychological make up of doctors. Apparently we have low self-esteem and want to solve all the problems of the world. I think that as doctors – indeed as humans – it is helpful for us to accept that there is pain in the world and we'll never completely avoid it. Even if we're all wealthy, and all have enough to eat – there will be other problems in the world. I think just acknowledging that pain is part of life; somehow it takes the sting out of it. The perception that you're not going to face challenges in life is an erroneous one. Life is full of challenges. I think once you accept that, it doesn't feel so bad.
I grew up with Roman Catholicism – I don't relate to it now. I think I'm probably much more aligned with a Buddhist way of thinking: mindfulness; working with the here and now, and what faces you in this moment; trying not to let the future overwhelm you or let the past drag you back. I also like Stephanie Dowrick's books. Forgiveness and other acts of love would be one of my favourite books. We don't need to hurt each other. You don't make your pain better by hurting other people. Nobody wins.
We've got some science and strategies around reducing mental and physical pain but there are, and I think there will always be, lots of people out there hurting. History tells us that people will probably continue to keep hurting each other, whether physically or psychologically or through other means. Humans have been around long enough for us to realise that somehow, we all own this.
I let patients who are facing all sorts of difficulties know that they are not alone. Not to minimise the way they are feeling, but just to let them know that other people have experienced similar things and have got through. I try to be compassionate and to find solutions that work for everyone.
As a doctor, it is very easy to let quantitative science take over, but quantitative and qualitative science are not mutually exclusive – they are complementary, and they answer different questions about the problem of human life. A drug trial, for example, can tell us which women should have treatment for breast cancer, and the survival rates, but it's not going to tell us what it is like to have breast cancer. They're different questions.
I think the medical community is accepting now that both ways of looking at human illness are valid, and that these two perspectives need to be talking to each other, rather than past each other.
You don't need to be super bright to be a doctor. I think you need to be a bit compulsive, a bit obsessive and a bit of a plodder. A lot of what we do may appear mundane, but there's nothing mundane about people.
Even if they've just come in with a bit of tummy pain, at the end of fifteen minutes you can tell them: "I think you're constipated, this is what you should do" – that's an exciting problem to solve. They don't have some interesting, complicated diagnosis, but you've helped them on their journey, and there's science around diagnosing constipation. If you don't like working with people, and you're more passionate about using your brain scientifically, then clinical medicine is probably not right for you.
I never find it mundane, but the problems people present with may not be very sexy. You deal with what comes through the door. It is never not a challenge. I might see three people in one morning, and I would do far more work than if I saw 20. It's not actually about the number of patients you see, it's about what you do with them. That's not really acknowledged.
It is interesting this whole issue of holistic medicine and 'alternative' therapies, because, being holistic isn't about whether you use mainstream medicine or complementary medicine. It is about seeing that you have a person in the room, for whom conventional medicine has some value, and so does some alternative therapy. There's no cookbook.
Everybody comes with different expectations. I've heard some horror stories of
people who have been to alternative therapists who have been very prescriptive, not been at all holistic, not made eye contact, and not actually asked: "Are you hurting? Is anything else going on in your life?" I've had one woman who actually went bankrupt because she was spending $20,000 per year on her therapies. She was very vulnerable and the practitioner that she was seeing did not even consider that she might not be able to afford this therapy that she was being told she had to have.
If I could give advice to patients I would say: "Choose a doctor who smiles at you, looks at you in the eye, and can laugh!" Do they ask you open questions? And do they ask you the basic things like: "Are you getting enough to eat? Is your house warm? Are you sleeping? Do you have someone who loves you?" These are basic but important questions – fundamental to being a well person. If your doctor doesn't ask you that, then you've got to wonder if you're on the same page.
If I were in charge of health care reform, I would suggest that we have an afternoon nap, drink milk, have a cookie at three and hold hands. That would be a good start. We might actually start talking nicely and listening to each other.
One of my underlying concerns in modern medicine is the commercial commodification of health and people's health data. One of our fundamental responsibilities as doctors is to avoid harm and to investigate, prescribe and treat in such a way that we are confident that we are adding value to people's lives. I believe that this must always involve shared decision making, which is not really appreciated by our funders. There are a lot of prominent people in positions of power in relation to health who like the sound of their own voice. I would not like to be a manager – it is not something I have any aspirations to do.
But when I see bad management and dysfunctional systems, I think: I've got to do something. There are a lot of opportunities to go to the relevant departments to point out some of the anomalies with what they are expecting us to do, which are not do-able. We need to start biting off manageable pieces and get some dialogue going. It's a bit like mountain climbing: getting to a summit is just very mundane – one foot in front of the other – just keeping on going. It is a lot of hard work but there is some thrill about plodding. When you look at a peak or squeeze through a bit of glacier, you don't say: "I'm going to get to the top," you just work on the bit in front of you. You say: "We've got the right equipment, we've got a good group of people, we're all looking after each other." All you can do is go with an open mind.
If you get to the top, great: if you don't, well, you still had a good day out in the hills. If I feel I have been able to create an environment where people feel heard, I feel I have succeeded. If someone opens up in real trust, sensing that you have their best wishes at heart, you may not always make the right decisions for them, but if they go out of the room feeling listened to, feeling heard, then that gives me a real buzz. Because I know what it feels like to be heard. Being listened to is one of the most amazing experiences of being human. When you've experienced being deeply listened to, it is quite powerful. You can never ever doubt the value, the inherent goodness of one human being trying to understand the life of another human being.
Beyond the Stethoscope
By Lucy Hayes
Publisher: Heartworks Press
RRP: $34.99
Release Date: July 1, 2019
There have been 69 vegetation fires in the last month.