What makes a doctor

As you near the end of medical school, there is a dawning horror that you're not actually finishing anything - you're getting closer to the beginning. After six years of filling your head to bursting with information, realising medicine won’t just ‘come naturally’ to you, watching in despair as the facts you learned last week leak out of your ears, finding that clinical skills have to be learned over and over and over - this realisation is quite a blow.

Almost everything I thought I knew about being a doctor has turned out to be wrong. I went looking for a career that would offer certainty, quiet intellectual precision and the humble piety of helping others. I thought doctors' stillness came from their surety.

What I found instead is a heaving mess of a thing - the blood and guts being the least of it. Hospitals crammed with people and patients and politics. Buildings that make little sense and organisational structures that make even less. So many good people. Plenty of sh**s of course, egos too. But my frame of reference for shitty people with huge egos came from working at Parliament, so it’s all comfortably relative.

“Be your least annoying self” was both the most useful and most disheartening advice I received about being a medical student, alongside the terrifying “every day is a job interview.” For us, the hardest thing isn’t the science; it's negotiating all the shades of grey (no, not those ones) in the relationships filtered through the hospital hierarchy. You should have “good banter” but not in handover meetings or during ward rounds. You must respect the pecking order but also speak up for yourself and for your patients. Be competent but not arrogant. Make the seniors look good, and they’ll look after you - if your seniors hate you, try and make them hate you less. Never do anything to piss off the charge nurse.

It’s a booby-trapped spider’s web and no matter how lightly you tread, any strand you tug will initiate repercussions somewhere. At the start of all this I told myself that I was looking forward to studying medicine because I’d be “leaving politics behind.” Six years deep, the memory brought tears to my eyes and I laughed myself sick, choking on my third coffee of the day.

The doctors who make the best teachers are the ones who love to show you all the worst things. They’re driven to wake medical students up to the reality of our patients’ lives. They want you to do house calls to the caravan parks, to work at the clinics at the homeless shelters, to visit the homes that have no power or are filled with black mould. You know they’re watching you out of the corner of their eye to make sure you hold your nerve and deliver care just as professionally as you do in the sterile GP clinic or hospital outpatient rooms. Often those doctors grew up in the communities they’re taking you back to, or somewhere similar. Empathy isn’t something they learned in a communication skills tutorial but something they possess as an intrinsic quality born of lived experience.

Enthusiasm for their specialty is the most potently attractive feature of a supervisor when you’re a medical student; someone who loves their branch of medicine or surgery, someone who can’t believe anyone would consider dedicating their doctoring to anything else. Those are the ones who lift students’ imaginations from the curdled swamp of our anxieties, competitive natures and petty disputes. They remind us that this was a life that we desperately wanted when we first applied to medical school. The opposite is also true. Students can sniff out an overworked and burned out clinician in a toxic department within the first five minutes of trying to ingratiate ourselves with a new team, and potential career pathways are mentally written off before you can say “zero tolerance for bullying.”

It’s an enormous debt because it’s hard to see what our patients get back from us in the early days. Timid and anxious, our questions are often rambling and our physical examinations haphazard. Our senior colleagues, either discreetly or exasperatedly according to their temperament, will have to return and redo our work - uncovering the pertinent information by pressing on an abdomen or auscultating a chest in a way that actually yields useful information. From our “first patient” - the donated cadavers who teach us anatomy in the dissection labs at the university - through to the people waiting anxiously to be seen in ED, to the post-operative patients recovering on the ward and everything in between, we are all grateful for, and humbled by, this gift.

Our final year is the best of them. Slung in the gap between medical student and junior doctor, we’re finally seen as a useful part of a team and given a glimpse of the autonomy ahead. This privilege for our cohort was overlaid by the global pandemic, disrupting and unsettling our expectations for the year but also giving us invaluable insight into how a health system responds to a crisis. None of us will forget what this was like, or how our senior colleagues stepped up to the challenge despite myriad personal tragedies as Covid-19 happened to them and their life plans too.

I’d love to have written this column without revisiting special entry schemes. I wanted to go out on a high, to show you the excitement and the privilege of the experience of learning medicine, and to share my immense gratitude for the special teachers I’ve had, our patients and my inspiring colleagues. But unfortunately I can’t ignore the context in which this essay will be published and I have a responsibility as a student who has come through the Māori and Pacific Admission Scheme (MAPAS) to address some of the issues raised in recent months with respect to the University of Otago equivalent of MAPAS - the Mirror on Society policy.

Sometimes, enough time passes that you start to believe that these pro-equity programmes are embedded, accepted and celebrated and that we can all just get on with our lives. But it never lasts, and time and again our Māori and Pacific medical students, doctors and academics have to divert their attention from the real work of helping people to the bruising and frustrating work of justifying our existence in the world of medicine. This year we have seen the legal challenge of a parent who felt so entitled to a place at medical school for their child that they wanted to restrict the University of Otago’s special entry schemes. A journalist who is supporting their campaign has written a number of opinion pieces leaning heavily on the old red herring of “hard-working students with extremely high grades are missing out.” As if the only reason someone would miss out on admission to medical school is because a brown student got in.

Nobody is entitled to entry to medical school, and there are always limited places available – irrespective of special entry schemes. I can’t speak for Otago’s process, but the one I went through at the University of Auckland included two sets of interviews with multiple examiners, submission of my grades from the first-year exams, and completion of the UMAT (now UCAT) three-hour clinical aptitude test. Grades absolutely form part of the picture, but you need a lot more than just being smart, and that’s what the admissions processes must test. A doctor’s day is not composed of regurgitating facts to examiners. It’s filled with hundreds of judgment calls, with negotiations between colleagues, navigation of the fiendishly complicated health systems specific to each hospital, and finding ways to communicate with patients and whānau with wildly different backgrounds and health needs. If you’re smart, but have no people skills or poor judgment, you’ll be a terrible doctor. We all know this, because we’ve seen them on the wards, in the GP clinics and in the operating theatres, and the people that ultimately suffer under the “care” of these doctors are the patients. Perhaps they are the legacy of historic admissions schemes that prioritised grades as the single predictor of someone’s suitability to be a doctor. If you look through the Health and Disability Commissioner’s catalogue of serious complaints, poor communication and bad judgment are the most consistent variables among the cases. It literally hurts people, and sometimes even kills them.

It’s interesting that it’s the Māori and Pacific entry pathways that get targeted in the media rather than the provision for other prioritised groups; these people want us specifically, as Māori and Pacific people, to feel guilty that we’re “taking” someone else’s place. In the “related stories” sidebar to these articles are stories about the terrible disparities in health outcomes in this country. These things are not unrelated.  

There are irrefutable data which tell us the health system does not currently do this. This is the only injustice we should be concerned with. The reality is that we are still short a couple of thousand Māori doctors relative to the population, despite graduating record numbers every year. Any delay to achieving this will set health equity back and our whānau can’t afford to wait.

I’d be lying if I said that we don’t take this sort of thing to heart occasionally. We do our best to have courage because our whānau aren’t going to get a more equitable health system if we’re sitting around feeling sorry for ourselves, but some days it’s hard when you watch people with no experience or knowledge of medical school or the health system publicly debate your right to exist in your chosen field or marshal the brains and resources of Twitter’s top devils advocate to OIA your brown colleagues’ exit grades from medical schools.

We watch all of this and know that some patients will wonder if we’re shit doctors because they read an article once on Stuff that said we got an easy ride through medical school because we’re brown.

This sad revival of an old, seemingly intractable prejudice has prompted me to reflect on the importance of solidarity among my colleagues. I’m grateful to our peers who understand what’s at stake and who respect their privilege to be doctors, and who are equipped to advocate for those who need us most. I think about that parent trying to shove their child into the medical school at the University of Otago by any means available and I wonder what they think the job is. Are they up for the ceaseless, insomnia-inducing, dispiriting work of health equity on top of everything else that a career in medicine asks of us?

So it’s not without some trepidation that I face this next bit. Not just because we’ve been spotlit this year by a campaign of ignorance and envy, but because the job is hard even without that hanging over our heads. I have sat across from junior doctor friends in hospital cafes as they cry tears of frustration and hurt at being bullied and overworked and I’ve been in too many private online chat groups talking colleagues off the ledge, offered too many times to have my phone on at all hours of the day “just in case” a friend finds themselves in a dark place. Progressing through the long years of this degree is a process of unveiling our eyes to the reality of the profession we’re entering.

In December I will formally graduate from medical school and our family will enter new territory. My daughter is six years old and I’ve been studying towards this goal since before she was born. One of her favourite leisure activities is getting me to practice clinical examinations on her, “Can we please do the cranial nerve exam māmā?” If nothing else I guess I’ve provided her with a rich source of material for therapy later in life.