BY ISAAC TANG

During the mid-year break, I came across a book in my sister’s collection that was small and slim (always a good sign!) with a rather benign, if not dull, title: A Country Doctor’s Notebook. I immediately assumed that it was yet another text about the joys and challenges of rural medicine to persuade more people to join its overburdened workforce. However, the blurb surprised me with some unexpected titbits of the book’s exotic setting and thrilling historical account – “twenty-five year old”, “lone doctor”, “depths of rural Russia”, “1916-17”, “eve of Revolution”. Moreover, this “lone doctor” is based off the first-hand experiences of the author himself, Mikhail Bulgakov (1891-1940).

With a large dose of dark humour and raw honesty, Bulgakov plunges into his collection of short but gripping tales. He uses many terms that are familiar to us as medical students but it is the stark differences in time, culture and medical knowledge that set these terms in shocking contexts, making the reading experience a surreal one at times. For example, we all know what an amputation is. But now imagine you are an intern on your first day as the only doctor in wintry, rural Russia without electricity and modern utensils and you have to amputate a girl’s leg. Plus, you have only watched an amputation… once. Some of us who have completed our women’s health rotation will know what a “transverse foetal lie” is and may have hazy recollections of a procedure called “internal podalic version” to help deliver this abnormally positioned baby. Again, imagine you are the same hapless doctor forced to do this for the first time in the middle of the night on an extremely distressed woman with only an obstetrics textbook to guide you.

For me, the anxiety is definitely palpable because I know for sure I would have collapsed under the same circumstances. Indeed, this poor doctor only has 2 midwives and a feldsher for assistance, with the footnotes graciously explaining that a feldsher is “a partly-qualified medical assistant” (emphasis mine). Despite his catastrophising thought processes and persistent self-doubt, the doctor, to my surprise and sometimes disbelief, carries out various surgeries and procedures successfully from pure determination and fortune. But Bulgakov also records some disastrous failures, including an unsuccessful internal podalic version which causes a baby to be delivered with a broken arm – and stillborn. In another instance, he accidentally pulls out a man’s tooth socket when he only meant to extract the tooth. In fact, when he sees the “enormous, jagged piece of gleaming white bone”, he almost “burst[s] into tears”. The doctor, that is. The patient has no idea what just happened as he is not told; he is only instructed to “rinse”.

This gives an appalling assessment of the culture of medicine back then – the paternalism and the lack of transparency. Bulgakov never records disclosing to his patients the fact that he has just graduated from medical school and has never done the procedures that he intends to perform e.g. tracheotomy, hernia repair. He does not even dare to inform his midwives or feldsher about that. Displaying a sense of arrogance and superiority also appears to be an expected part of early 20^th century medicine, especially towards the illiterate, impoverished and superstitious peasants Bulgakov encounters. There is no hesitation in directly denigrating a patient and their relations. A patient’s emotionally distraught grandmother is called “stupid” and promptly “pushed out of the room”. The doctor scolds and berates patients who do not accept his advice and he laments patients who present late in severe stages of disease. Understanding social determinants of health was clearly not core learning then, for he fails to appreciate the long distances his patients need to travel and the poverty and strenuous farming that characterise their difficult lives.

However, he does recognise that there are systemic problems that must be solved. Most of his stories are set at night, symbolising the overwhelming darkness of ignorance that he has to fight. He realises that health literacy and education are needed for a population to remain healthy. When he discovers an increasing number of syphilis cases in his catchment area, he begins to record his findings and reflect on how he can better convey the seriousness of the illness to his patients. Written before the discovery of penicillin, the proposed treatment of syphilis consisted of inconvenient, regular application of mercury cream on the skin that the patients had to adhere closely to. He also knows that he must have more doctors working with him to adequately meet his patients’ needs – a request to his employers that goes frustratingly unfulfilled.

His stressful working conditions are shown to have a great impact on his mental health. He never fails to remind us that he passed medical school “with distinction”. Yet he suffers from imposter syndrome, harbouring numerous fears that, out of shame, he feels compelled to hide behind a veneer of confidence and self-sufficiency. Before he runs off to peek at his textbook again, he tells his midwives he is merely gone to get cigarettes. Seeing approximately 100 outpatients a day and caring for 40 inpatients, he feels that he is gradually losing his personality. His irritable outbursts towards non-compliant patients likely signify his burnout. Thus, news of a violent blizzard is received “joyfully” as patients are prevented from reaching the clinic, allowing the doctor and his assistants a short-lived reprieve. In a tragic turn of events, he later receives news of a doctor acquaintance who loses his life after years of battling morphine addiction in secret. What makes things sadder is that Bulgakov does not reveal in this book that he himself had become addicted to morphine. Despite continuing to specialise in venereology, he eventually quitted medical practice to become a full-time writer.

In many ways, A Country Doctor’s Notebook shows us how far medicine has progressed and really instils in me a sense of gratitude for the improved conditions that we work in. But some issues touched on in the book still haunt us today in some way – poor health literacy, underserviced rural populations, the difference between medical school learning and actual practice, doctors’ mental health. Placed in an unfamiliar setting, this short book bursting with thought-provoking tales ultimately gifts us with a unique yet relatable perspective on what it means and what it takes to be a good doctor.

BY ROBIN CHEAH

I’m one-and-a-half years into medical school and I can already say I’ve been lost multiple times.

‘Lost’ is, admittedly, a broad word. It’s a word with a myriad of possible meanings: emotionally, socially, physically, academically, acutely, constantly. But that’s what makes it so powerful. From making a wrong turn and ending up at anatomy 15 minutes late, to feeling utterly overwhelmed by content, to reflecting on what my goals even are – no word has encapsulated medical school quite as well as ‘lost’.

It’s easy to feel lost in the academic rat-race; barrages of content, an increasingly vast repertoire of examinations and symptoms and special tests and eponymously-named signs to not just remember but also understand. One moment, it seems achievable – “I think I remember all of this systems review” – and another moment a revision lecture or practice exam topples all of that down. It’s an erratic tide that rides highs and trembles at terrible lows – the short-term panic attack in a tute where you know utterly nothing –  with no ultimate direction. Sometimes the wave does vaguely point somewhere – “I need to know more about this” – and those moments of curiosity are refreshing when they arise.

Adding to the confusion, there are those quasi-clichés such as “preclin doesn’t matter” or “It’s not on the exam” creeping into every second conversation. It instills a constant uncertainty: what truly matters and what doesn’t? Am I wasting my time on things that don’t matter? Am I just wasting my time studying if I’ll learn everything on the wards? Everything academic becomes ambiguous; every assignment is distilled into a weighing scale of effort with outcome. An essay might be pass-fail, but it’s also an opportunity to learn something important – but there are also exams nearing, that group assignment, the new thyroid examination to revise. Is all this theoretical content even important? Doing well on exams doesn’t really matter, right? The questions sometimes pile up into an incomprehensible heap regardless of where you think you are.

But being lost extends to more than just study – life is more than that. Acronyms for interest groups can fly over one’s head, leaving only the question of specialties (harkening back to the “What do you want to study in uni?” of VCE days). Even if there is no expectation to choose or commit or even consider, its ubiquity as a conversation topic makes it seem like there is sometimes. It can feel like a constant reminder that you don’t have goals, that you’re indecisive and God forbid, can coalesce into self-judgement.

It’s easy to judge yourself for being lost, for all its meanings. Being lost academically means you’re not smart enough or hard-working, or that you’re trying too hard or wasting effort. Being lost socially means you’re not good or nice enough to be liked. Even not having concrete goals feels like you’re indecisive. This is perhaps the point where that wave of ambiguity swells into a tsunami that drowns you in doubt. It is truly dangerous, especially when there’s that constant calling to keep revising, keep studying, keep up with the new content and lectures and go to class. It can be hard to stand firmly when you’re drowning like that.

In a way, the idea of feeling lost and unsure grows sobering; it’s somehow paradoxically reassuring to know that it’s the norm. Maybe what one needs is just to put their head down and do what they’re doing, but with conviction and confidence. Perhaps what we all need is to forgo the “It’s up to you” and make a decision ourselves as to where to go and what to do; resultantly, we’ll reap the rewards and pay the prices. Alternatively, you get acquainted with being lost, accept it and understand it’ll be there forever and as a result become numbed to the uneasiness it brings. But those are just two possibilities; the outcomes are infinitesimal, rightfully so for a term that has so many meanings.

Will that seemingly-omnipresent uncertainty ever fade away? Being lost in a hospital definitely sounds like it could happen. Being lost in the content of clinical years sounds more like an inevitability than anything. And it’s not even a medicine-specific struggle, either — there’s uncertainty in university life regardless of course.

Maybe being lost and uncertain isn’t an enemy but rather a friend we’ll get used to.

By Sophie Skuza and Dana Boden (MUMUS Gender Equity Committee)

Trigger warning: sexual harassment and sexual assault

The voices of women have dominated the Australian media landscape over the last two months. To recap, we’ve had 4 allegations of rape against one man in our Federal Parliament, a historical rape allegation brought to light against one of the most high profile people in Federal Cabinet, and a petition started by Chanel Contos to teach comprehensive sex education in schools at an earlier age. 

These events, along with International Women’s Day on March 8th, have contributed to the recent widespread outrage felt by many individuals across the country, and resulted in the nation-wide Women’s March 4 Justice held on March 15th.

While, at first glance, these issues – namely gender-based discrimination and the sexual assault of women – might not be strongly connected to the medical profession, the reality is that these issues are still commonplace. Within hospitals and other healthcare settings, to this day, there exists the rampant mistreatment of women, both as patients and as colleagues. Women and people of diverse genders still face challenges every day, which is why the battle for gender equality is so important.

Take the case of Dr Caroline Tan, a neurosurgeon whose career was derailed after she spoke out against the sexual assault she experienced from a senior colleague in 2005. Despite winning the case against her senior colleague in 2008, Dr Tan believes that her decision to take action against the sexual assault she experienced contributed to her being shunned by other surgeons and repeatedly overlooked for positions within both public and private hospitals. During her VCAT hearing, Dr Tan was accused of fabricating her sexual assault experience as an ‘excuse’ for her poor work performance. She was forced to relive her assault in vivid detail, while her authenticity was criticised when she couldn’t recall exact details about the “colour, size, or shape” of her abuser’s penis. It was also revealed that the individual she initially reported the assault to, the head of her department, responded to the tune of, “What do you expect when you dress the way you do?” after she disclosed the details of her assault to him. Dr Tan’s abuser did not face any disciplinary action, and he continues to work with the same employer (at Monash Health).

Dr Tan’s case was referenced by Dr Gabrielle McMullin, a Sydney vascular surgeon, at a function in 2015. Dr McMullin, who, rather than praising Dr Tan’s strength in reporting her assault, made the shocking and heartless suggestion that surgical trainees should stay silent and complicit if they have been sexually assaulted by a colleague, as speaking up about their abuse could have consequences for their careers. She went on to say; “What I tell my trainees is that, if you are approached for sex, probably the safest thing to do in terms of your career is to comply with the request. The worst thing you could possibly do is to complain to the supervising body, because … you can be sure that you will never be appointed to a major public hospital”.

Possibly the most horrifying part of Dr McMullin’s speech was when she said Dr Tan probably would have been “much better [off] to have given [her abuser] a blow job on that night”.

“This unacceptable abuse of power is unfortunately far too common within the medical profession, especially due to the strength of hierarchical structures existing within hospitals”

This unacceptable abuse of power is unfortunately far too common within the medical profession, especially due to the strength of hierarchical structures existing within hospitals. The entrenched belief that women should simply accept and comply with unwanted advances to further their careers serves only to subjugate women while encouraging further violent and illegal behaviour from men. It also contributes to the attitudes surrounding misogynistic statements such as, ‘she slept her way to the top’, rather than revealing the reality of this statement: ‘she was taken advantage of by men who use their positions of power to dominate women’’. Furthermore, Dr McMullin’s comments disempower women from seeking counsel after they have experienced sexual harassment or assault, causing profound feelings of shame, hopelessness, and trauma.

The case of Dr Caroline Tan is disturbing, tragic and outrageous. Her story is hard to hear, and it is a stain on the medical profession that we should all be ashamed of. But rather than just accepting her story, we have to change the narrative. We must ensure there are no more individuals treated as Dr Tan was, and rather than victim blaming and coercing women into silence, we must encourage them to speak up, and support them whilst doing so. We cannot continue to live in a world where the choice exists between a woman’s career and her safety.

It begs the question: what can I do to help?

The theme for this year’s International Women’s Day is “choose to challenge”: why not challenge yourself to be a stronger ally for women and other people of diverse genders, or challenge others to change their behaviour towards women?

• Call out misogyny and other gender-based discrimination/prejudice.
  • If you hear others, including your friends and family, speaking about women in a derogatory way, stand up for women and tell those individuals that the way they are speaking is not ok.
  • If you see a woman being bothered or harassed, walk over and support her.
• If someone opens up to you about sexual harassment or assault, do not victim blame them. Listen, hear, and encourage her to report. Do not get defensive or pass it off as unimportant/insignificant.
• Advocate for women’s issues and other gender-diverse issues – sign petitions, attend protests, spread information!

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The MUMUS Gender Equity role was founded in 2018, and since then the Gender Equity team has worked hard to bring representation and inclusivity to Monash Medicine through four key areas: curriculum, social media, community building and advocacy.

In the past few years, great things have been accomplished, including:

• Making the anatomy curriculum more trans inclusive by changing male/female to assigned male/female at birth
• Introducing asking sexuality into the reproductive history, to avoid assumptions of straightness
• Introducing pronoun stickers to clinical student name badges
• Data collection to ensure MUMUS is accurately representing the medical student body
• Upskilling events with panels of incredible female-identifying medical professionals

In 2021, we hope to bring even more inclusivity to the curriculum, as well as running incredible events, building community through our Facebook group SafeSpace, and spotlighting incredible health professionals on our socials!

By: Bowen Xia 

For: The Auricle Writing Competition 2018

Prompt: ‘What is a piece of advice you wish you hadn’t taken and why?’

In a small house, a year 6 student sits in a dimly lit room studying hard all day to prepare in the hopes of entering a prestigious selective school. Surrounding him are boxes of certificates, medals and trophies of various competitions and outside that, on a patchwork couch, his parents and siblings huddle together watching the latest episode of the ‘Simpsons’ on an old box TV. They ask him to join but he has more important things to do. Ha! His family’s periodic bursts of laughter mix over the TV static and he blocks his ears. One day my hard work will pay off and then I’ll be truly happy.

6 years later…

In a prestigious high school, a year 12 student sits in an empty classroom studying hard all day, to prepare for his VCE exams, in the hopes of studying medicine at a prestigious university. His blazer is adorned with numerous academic and leadership badges and his brow is furrowed and beaded with sweat whilst gazing at the citric acid cycle. Bam! A ball hits the window and shouts of his friends playing outside fill the room he shuts the window and closes the blind. One day my hard work will pay off and then I’ll be truly happy.

4 years later…

In a prestigious university, a fourth-year medical student sits in the medicine building foyer silently studying hard all day, to prepare for his end of year exams, in the hopes of gaining an internship at a prestigious hospital. In his bag sits his Netter’s flashcards, four medicine textbooks and his trusty Classic III stethoscope. Slam! The silence is broken as his peers leave the building for their weekly pilgrimage to the ‘Nott’. He stares back at his Anki cards. One day my hard work will pay off and then I’ll be truly happy.

3 years later…

In a prestigious hospital, an RMO sits in the staff breakroom revising hard all day, when he is not on shift, to prepare for his eventual registrar exams in the hopes of joining a prestigious speciality. On the table sits his fourth cup of coffee, a Cardiology III stethoscope, two patient files and a model of the brain. Creak…! Some colleagues leave the room and head off to Zoukis for a well-deserved break, but he resolutely refocuses on his studying. One day my hard work will pay off and then I’ll be truly happy.

9 years later…

At a recently founded clinic, a neurosurgeon sits in a consulting room working hard at night. It has been a long day chock full of patients and paperwork but hopefully, he will be finished soon. On his desk sits a framed picture of his family, a pile of bills, a neatly drafted cover letter and a brochure titled ‘AMA Nominations Opening Now!’. Click…! He opens the main door to his house. All the lights are turned off except a small night light in the lounge room where it shines dimly on the couch and two small sleeping figures are illuminated. He picks up a piece of paper lying next to them and inspects it. A squiggly drawing of his family is on it and underneath is scrawled ‘please come home soon Dad!’. A tear rolls down his eye. One day my hard work will pay off and then my family will be truly happy.

12 years later…

In the nation’s capital, a high-ranking member of the AMA studies some documents in his empty boardroom. When he is not attending meetings all day, he prepares his family’s finances. In his wallet sits a real-estate business card, a prescription for Xanax and a well-worn photo of his children. Ding! A message appears on screen ‘where are you dad? I can’t see you in the audience from the graduation balcony’. As the Prime Minister and his panoply of staff enter the room, the text message is dismissed with a sigh. One day my hard work will pay off and then my family will be truly happy.

20 years later…

In an inviting, large, well-kept house no one enters except for the occasional cleaning staff. On the balcony, a recent retiree idles all day on a sunchair waiting for the clock to strike 5:30 pm. In a bin next to him sit two empty pill boxes, one bisphosphonates and the other NSAIDs, and a torn brochure titled ‘Europe travel guide’. Beep… beep… beep! He unsteadily gets out of the chair and shambles towards his phone. Every movement seems to be painful but made with determination as he stops the alarm. His daily ritual has begun as he calls the two people that matter the most to him. Both go to voicemail but not without him sending two text messages that are left on seen. As the sun begins to set and the darkness approaches, he begins writing a letter.

My dearest angels,

I am truly sorry that I could not make you happy, but I hope this letter can. Fifty-four years ago, I a young, eager boy promised myself that I would not stop pushing forward into the world until the right moment to enjoy life to its fullest arose.  Alas, that day arose too late and I an elderly frail man will bountiful time and material can make neither you nor me happy.

 I blame this on ill-disciplined motivation and determination and insufficient time. If only, my promise was made when I was younger, and I tried working harder, today’s grief would be avoided. Our past conflicts were due to our different outlook on life but as your father, I cannot let you continue making the same mistakes as me. I implore that you resist being complacent and discontinue your premature enjoyment of life. If you do not stop working hard for the future, you may be happy in the end.

With Love,

A Sorry Old Man