I could probably end the post right here, because the title says it all. But that’d be a bit of a cop-out, I suppose. Anyway, I’ve always been one for doing things “the hard way”, so I’ll proceed now to bore you with all of the painful details.
Why this post, and why now? Because I’ve been hearing a lot of “you should go back into practice” lately. And I know you think I should, but you’re wrong, and I’m going to tell you why.
It surprised me to realise that I haven’t actually written about this yet; at least, not in any great detail. I’ve touched on the “it’s complicated” relationship status that I have with medicine in a few different places on this blog. And, if you read my totally-amazingly-mindblowingly-awesome book, you can get a whole lot of candid honesty about some of the experiences I’ve had with the medical establishment, both as a colleague and as a patient. But I haven’t really found the space to put all of it together, and reflect on what it all means, and how I feel about it at this point in my life.
Let me start off by clarifying a couple of points, which I’d like you to bear in the back of your mind as you read the rest of this piece:
Originally, my motivation for entering the medical profession was rooted in altruism
Yeah. It sounds corny, or like a cliche, but it’s sincere. I wanted to help people – it’s a vague aspiration (and a lofty one), but it seemed like medicine was a good avenue for me to do some good in the world. And there was the added benefit of not having to figure out how to do some good – because it’d pretty much involve just doing my job. Makes sense, doesn’t it?
Yes, I do miss clinical practice
I was a good doctor. “A good doctor” – what does that even mean? It means that I was good, that I was a doctor, and that I was good-at-being-a-doctor. This is my own opinion, of course, but there have been many other people who have said the same about me (colleagues, employers and patients). I know that I made a difference to peoples’ lives, on some scale. I enjoyed being good, and I enjoyed being a doctor, and I enjoyed being good-at-being-a-doctor. It was rewarding and fulfilling, make no mistake. Having said that, it was also frustrating, exhausting, draining, and painful. Medicine exposes you to the best and worst of humanity, often simultaneously. There is a lot of conflict and complexity to navigate, and it’s difficult to find the right balance. I loved it – this isn’t in dispute. But at the same time as I loved it, I also hated it, or just felt generally mixed-up about it. More on this to come.
Let’s travel back through time, shall we?
It’s 2003, and I’ve been out of school for a while, and I’m trying to figure out where my life is going. Everyone is telling me not to even consider medicine. Up to now, I hadn’t even said the “m-word” – but somehow, there is an assumption that if you’re AJAB and smart, medicine is automatically at or near the top of your list of considered vocations. So, of course, I think about it. And it seems like just what I’m looking for. A grueling profession, where I can sacrifice myself on an altar of altruism, forfeiting free time, personal happiness and wellbeing for the sake of a greater good.
Back in 2003, I didn’t like myself very much. I didn’t think I deserved any kind of happiness anyway. I didn’t think anyone would ever love me. I felt like I had some massive transgressions for which I needed to atone. I felt like a lost cause, and that this was the only life I’d ever be fit for.
Dysphoria’ll do that to ya.
Medical school wasn’t a fun place to be, in all honesty. There was a lot of suffering and hardship and anxiety and pain to which I was subjected during those 6 years. But I endured, and eventually I emerged from the medical education system, scars and all.
Out of the frying pan into the fire.
It’s 2010. Internship and community service came next. Working in under-resourced hospitals in rural Mpumalanga, with no support and no supervision. You know how you only really learn to drive after you have your licence? Well, medicine is kinda the same. So there I was, thrown in the deep end, lives in my hands, and I had to figure it all out on my own. I remember managing entire wards of patients alone, I remember working multiple overnight calls a week, I remember nights in casualty where the stream of critically ill or injured patients just didn’t cease.
Under those circumstances, it becomes difficult to keep seeing patients as human beings. It becomes difficult to keep seeing yourself as a human being. It becomes difficult to keep on giving a shit.
Not seeing myself as a human being wasn’t all that much of a problem. I hated myself, remember?
But I recall being scared of myself, when I had been pushed to the limits of human endurance. I recall looking in the mirror at 3am, coming face-to-face with the depletion of my compassion. I recall that it terrified me.
I didn’t like myself. But I especially didn’t like what the system was bringing out in me. I especially didn’t like the person I needed to be in order to survive.
I have a stack of stories from those days.
I can tell you about the patient who showed up in the middle of the night, his chest cavity rapidly filling with blood and air, who would have died if I hadn’t forced a thick hose-pipe in between his ribs, to allow his lungs to inflate again. That hose-pipe is called, in medical terms, an “IC drain”. The catch? I didn’t know how to place an IC drain. I’d never done it before. And there was no-one around to show me. That patient owes his life not to me, but to Google, and the instructions it provided me that night.
Or I can tell you about the woman we took to theatre for a C-section, my first day on the job as an intern. How I stood in theatre, following instructions, assisting my supervisor as he took the baby out. How I was powerless when he refused to stitch her back up, how he insisted on removing her fibroids (benign muscular growths that sometimes form inside a uterus) at the same time. “This will be good for her,” he’d said. Fibroids can cause bad periods, and they can make a woman infertile. In fact, this woman had struggled to conceive – and the fibroids were undoubtedly the cause. But during a pregnancy, a uterus engorges with blood – the arteries and veins expand massively. And a fibroid is already a very vascular thing to start with. Removing it during a c-section is a spectacularly bad idea, because if you do, you can’t stem the bleeding that follows. But my supervisor was insistent. She died in ICU within the week, the child she had struggled so to conceive now left an orphan.
I have many more stories like that. I try not to think about them too often.
I had many role models during those years. Shining examples of the kind of doctor I never wanted to be.
In fairness, they weren’t all bad. There were those rare occasions where I’d meet and work with someone who still managed to be good, and managed to be a doctor, and managed to be good-at-being-a-doctor. But they were outnumbered, vastly, by the rest.
By the time I’d completed those years, I was on the verge of burning out. In fact, if I think about it carefully, I’m sure I already had burned out.
2013 now, and my next stop was private practice. It was a little better. At least the hours were predictable. At least we always had enough gloves, and alcohol swabs, and sealed sterile needles.
The private sector has its own unique set of challenges. I had to learn how to navigate the intersection of customer service, capitalism, and ethics. And it was all made trickier, because I was working in someone else’s practice.
For all the wonderful interactions I had, and for all the lives I changed or touched (or, on more than one occasion, saved), there were as many times when I felt disenfranchised, or manipulated, or held to ransom by the system and the demands to which I was subjected.
For all the fulfilment, and all the satisfaction, there was still conflict and anguish.
Late 2015. I’ve acknowledged by now that I’m trans, and that I need to transition, and that if I don’t get onto hormone therapy, bad things are going to happen. For the first time in a long time, I am the patient. I encounter a bunch of different doctors in my attempts to access care. Psychiatrists, GPs, endocrinologists. They demean me, insult me, question my identity. They ask me things that are not just invasive, but irrelevant – information to which they have no right. I jump through their hoops, because I am desperate for help. I am unwilling to self-medicate – because, for the first time in my life, I am learning how not to hate myself, and I want to be responsible. They effectively tell me “I’m not trans enough” and they don’t believe me because I haven’t been in therapy long enough. When I do eventually find doctors willing to treat me, they treat me as an object, rather than a person. I’m a diagnosis, or a lab-result, not a human being. Not just that, but they mismanage me. Prescribe the wrong medications and the wrong doses. And when I point it out to them? It becomes clear that a doctor’s ego is more valuable than a patient’s well-being.
I learn the hard way that the responsible thing to do is, in fact, to self-medicate.
Concurrent to all of this, I am facing up to the reality that I will soon have to leave the practice where I work. I begin planning for the future, because that’s just how I am. I think, naively, that my identity might be an asset rather than a hindrance. I approach some of the university departments that are treating trans patients; I reason that since they are working with patients like me, they’d value having someone like me on their team. And I’m enthusiastic. I want to keep doing what I do. I even buy a new stethoscope (pink, of course), in preparation. I’m told, by multiple different people in multiple different departments at multiple different institutions that I’m not welcome. That I wouldn’t be safe. That they’re not ready.
I’m waiting for an ID amendment that ultimately will still take another 11+ months, but I send off CV’s and job applications to a bunch of different places. Private sector, public sector, health insurance companies, pharmaceutical companies, corporations, NGOs. Because they all need a copy of an ID, or a university degree, I have to “out” myself on the cover letter. Not one of them calls me back for an interview. No one says, “it’s because you’re trans”. Well, no one says anything, in fact. There is just silence. But I know what the silence means.
I toy with the idea of opening my own practice. At this stage, I am still hopeful that my legal name change will be processed quickly, because I can’t practise under a deadname. I start looking at potential spaces to rent. The real estate agent is very friendly and helpful and cooperative. She takes me to view some premises, and they look promising. She assures me that she’ll send through the floor plans within the week. During the days following our meeting, I’m interviewed on national radio, speaking about my experiences as a trans woman. The next day, I receive an email from the realtor:
Thank you for your enquiry, however I am unfortunately unable to service your request at this time.
She doesn’t say, “it’s because you’re trans”. But I know what the email means. We don’t live in a world where real estate agents are “unfortunately unable to service your request”.
During the time that follows, I become more visible. I do media interviews, I do training workshops, I start writing a blog, I am very public across social media. Other trans people, knowing that I have a medical background, are very forthcoming in sharing horror stories of their own encounters with the healthcare system, and the ways they’ve been abused by their service providers.
Some of them have been prescribed medication that is unnecessary, costly, and potentially dangerous.
Some of them have been denied access to hormone therapy unless they consent to being sterilised.
Some of them have been physically abused by their service providers.
Of course, it’s not just trans people who are mistreated by their doctors.
Doctors don’t explain. Doctors don’t get consent. Doctors don’t take the time to treat you like a human being. Doctors don’t believe what you say. Doctors make all the decisions.
I know why they are like that; because the system that teaches them their clinical skills also strips them of their humanity. I have been through that same system myself. It is the same system that could not tolerate me once I came out. A system that is threatened by my individuality, by my compassion, by my refusal to buy into its norms and standards. The same system that abused me, as a patient and as a clinician. The same system that ultimately, I rejected as a patient and that rejected me as a clinician.
I am not sick, or broken, or defective. But the medical establishment? It is. Sick and broken and defective.
Now, a year and three months since I hung up my stethoscope, I am in a position where I have the theoretical capability to go back into practice. My name is changed, my university degree is amended, my professional registration is updated.
I could be a good doctor. I could be good, and I could be a doctor, and I could be good-at-being-a-doctor.
And I would be one good doctor. In a system that is sick and broken and defective.
One good doctor.
I could sit in some cozy office, with plush trappings, and some nice art on the walls. Seeing patients that can afford to reach me, that can pay for blood tests and medication, that can afford my consultation fees. Notwithstanding, of course, the potential social backlash and consequences that I might face for being so openly queer and trans and daring to have my own practice.
I don’t hate myself anymore. It took me a long while to get here, and sometimes it’s difficult to hold on to it, but I am in a space where I want the best for myself. I want to give as much as I can, and I want to live a good and happy life while I’m doing so. I don’t want to waste any part of me. So yes, I am a good doctor. But I’m also a good writer, and a good speaker, and a good teacher. A good storyteller. And every moment sitting in that cozy office is a moment that I’m not writing, or speaking, or teaching, or telling stories.
Yeah, I could touch a good few lives. One patient every fifteen minutes, for eight hours a day, five days a week, for the next thirty or forty years, until I die or get sick of it, and then leave them all stranded.
But it’s not the patients who are in the most dire need of being treated.
It’s the system.
So no, I’m not going to be one good doctor in a bad system. Instead, I’m going to do my damnedest to fix the system. And, maybe one day, when that system is full of good doctors… well then, maybe-just-maybe, I’ll want to be one of them.
You can read, in much greater detail, about my experiences as a doctor, as a patient, and as a trans woman in my book, Always Anastacia. It’s available at booksellers across South Africa, and worldwide through Amazon. Catch up on all the latest #AlwaysAnastacia news, including interviews, media appearances and extracts here.