BY SURINA BUTLER

The following creative piece was inspired by a patient interaction

Silence is punctured by the incessant cough, cough and the pinging of machines. I exhaust myself after another coughing fit, and then lie back, closing my eyes to shield them from the piercing lights above.

‘You have a very rare type of pneumonia,’ the doctor’s comments from yesterday echo in my mind. I can visualise him clearly in my memory, layers of material protecting his body. His voice is muffled by his face mask, and yet he still chooses to speak softly. ‘We call it an ‘AIDS-defining’ illness. The bug inside your lungs is a fungus that causes infection in people with a poor functioning immune system. The infection is called Pneumocystis jirovecii pneumonia, or PJP. The bug can only grow because the HIV has made your immune system weak.’ The last word branded me like a white-hot iron – weak. As if on cue, I coughed at that exact moment. My immune system was signalling to the fungus that I am weak – have your hostile takeover, I will not fight you.

In 1997 at 30 years old, I was diagnosed with HIV. I told very few people, keeping my secret close. It left a black mark on my soul – an ‘x’ for the virus to find and take up residence. It consumed a part of me.  

There was new treatment for HIV being introduced. They called it ‘HAART’ – highly active antiretroviral therapy. A friend told me to ‘stop feeling sorry for yourself, the stigma is dying down in Australia – get on with the treatment and live a normal life with the virus.’

He should have known better, because I wasn’t normal. Stigma can be external, but it can also be internal. Public disgrace was one issue, but I found that self-disgrace was always more overpowering. Self-harm was my disgusting delight. And here was my means to hurt myself over and over. I was diagnosed with Bipolar Disorder in my thirties. A ticket to ‘the rollercoaster’, as I liked to call it. And so began alternating periods of depression and mania. Pervasive self-hate was there throughout. I took my HIV medication more often during the manic periods, and far less during the depressed times. The end result was doctor after doctor and friends and family telling me that I needed to take my medication because I was making myself sick.

Stigma can be external, but it can also be internal. Public disgrace was one issue, but I found that self-disgrace was always more overpowering

When I started developing mild sicknesses I paradoxically felt better. ‘You deserve this’, I told myself. My mouth would be filled with putrid yeast, sitting in yet another psychiatry ward. Influenza season would take me as its victim every year. I remember with the slip of my hand while cutting open boxes, I created a wound that stubbornly refused to heal for weeks.

A psychiatrist once told me that every psychiatric disorder houses some form of deliberate self-harm. The patient with anorexia nervosa starves themself, the patient with obsessive compulsive disorder washes their hands raw, and I was no exception. I was the depressed and manic patient who let their HIV rage on unchecked when I was out of hospital.

Depending on who you asked, my self-disgust was rooted in many different spots. My father’s staunch Catholicism, and the doctrines he was taught (‘homosexuals are abominations’ – he would tell me), the alcoholic uncles who taunted me, the partners who hit me to assert their dominance, and so the list goes on. The end result was an internal tangle of gnarling branches, tearing me apart.

I found ways to evade the healthcare system. I stopped attending all appointments. When I moved to a distant suburb, I was out of reach of the system. I could feel the pain I needed to feel, and when it was too much, I would drink to forget what I had done to myself.

However, I had forgotten to account for my aunt. She visited me annually, or sometimes every other year. She managed to track me down and found me in a drunken stupor one afternoon. I can imagine the scene she would have walked in on. Around the room she would have seen remnants of a recent manic phase. Projects that were started and immediately abandoned strewn around the room – one eighth of a novel manuscript torn to pieces, empty bottles of pinot and a collection of photos folded and ripped littered across the floor. I have vague recollections of the next few days. Red and blue lights. The acrid scent of disinfectant. Blood flowing out of my veins and collected as evidence. Evidence of my many failures. Stethoscopes firmly placed on my chest and back. The doctors told me about my pneumonia, and diagnosed me with ‘AIDS’. I internally congratulated myself. Officially inducted into the club.

The psychiatrist visited yesterday, or perhaps it was the day before. Time is passing confusingly. She told me I needed to engage with psychiatric help. She would find the right program for me.

‘Do you know where the word stigma originates from?’

‘It’s a Latin word to describe marking the skin or body with a hot iron,’

She said, ‘the stigma surrounding HIV is lessening, and you need to engage with help’.

‘Doctor, do you know where the word stigma originates from?’ I asked.

‘No,’ she sighed.

‘It’s a Latin word to describe marking the skin or body with a hot iron,’ I paused, ‘maybe the world is moving on. Maybe they now say that people with HIV can lead a normal life. But the stigma inside of me never lessened. I branded myself with a hot iron, and now this is my cross to bear.’

A distant beep in the hospital brings me back to the present. I exhale and the burning slices through my chest. Then silence, punctured by a cough, cough and the pinging of machines.

By ANONYMOUS

Mark (pseudonym), a fourth-year medical student from Mxxxxx Uxxxxxxxxx, expressed annoyance at his 5th visit to a COVID testing site since he commenced his paediatric rotation at Mxxxxx Cxxxxxxx Hxxxxxxx 7 weeks ago. “That is more than the number of OCEs I have managed to get done!” he complained to a friend.

When he had his first COVID test 6 weeks ago, he was filled with trepidation – Does the test hurt? Could I really have COVID? Did I wear my N95 mask properly? Did I perform hand hygiene 99 times instead of 100 times on Wednesday? Does the test hurt?

However, upon questioning today, Mark no longer had any fears. In fact, he did not even smile at the person doing his COVID swab and hoarsely answered all her questions before she could ask them. “Not your first time?” the nurse asked, with a broad grin.
Mark did not have the energy to answer, simply blowing his nose in a tissue as she prepared the swab. Mark had noticed that his respiratory symptoms were always preceded by the same event – namely, being coughed or sneezed on by a “cute” and “adorable” child who also happened to begin a monstrous, high-pitched wailing noise when any attempt to examine was made. From behind his N95 mask, Mark had watched, with a degree of wonder mixed with disgust, the cloud of particles that aerosolised from the child’s gaping mouth. “Trillions,” he estimated, generously.

As Mark drove home, he noticed that the upper part of his nose was unusually tender. “The swab must have been pushed too far this time,” he grumbled. As some clear fluid ran down his nose, his mind temporarily entertained a discomfiting thought – “perhaps it is a cerebrospinal leak?” He made a mental note to look out for headache and neck stiffness.

However, there was another issue worrying Mark – why exactly had he been getting sick so easily? He monitored himself closely – no polydipsia, no polyuria, no loss of weight (in fact, the opposite), no loss of appetite, no bruising, no petechiae, no splenomegaly, no unhealthy meals (usually). He checked his box of antihistamines and satisfied himself that it contained no corticosteroids or immunomodulators. After his URTI resolved, he discussed this with a fellow medical student, who suggested that perhaps he was stressed. “Maybe you have worked on too many matrix conditions?” he suggested helpfully. “But I haven’t started on the matrix yet!”

After this conversation, Mark returned to paediatric ED, where he was greeted by the charming sight of a little boy vomiting copiously into a bag. Mark felt he wouldn’t be surprised if he had these symptoms in a few days’ time. “Hopefully, it’s not norovirus…” He then groaned when he remembered that GI upset was also considered a symptom of COVID-19.

He mentally prepared himself for his impending 6th COVID swab.

By Sinead Murphy

As a second-year medical student, fresh out of our first cardio clinical skills tute – I used my shiny new Littman to listen to my own heart. Almost unsurprisingly, I heard a murmur.

This is a common story, so much so that a ‘Grade 0 Heart murmur’ has been jokingly coined as a murmur only a medical student can hear. But the difference was, this heart murmur didn’t go away as I listened to more and more normal chests. It didn’t go away when I watched heart murmur video after heart murmur video on YouTube. It still didn’t go away when friends reassured me that they were pretty sure it was normal.

Finally, I visited a GP, and without listening to my chest she told me to stop being an anxious medical student, and to never do examinations on myself. A couple of months later, a much more understanding GP, an echocardiogram and a cardiologist later, it was confirmed that I had a bicuspid aortic valve, and an (admittedly benign) flow murmur.

A close friend of mine woke up in the middle of the night with pleuritic chest pain and an impending sense of doom most of us are lucky enough to have only experienced in the ‘Presentation’ section of BMJ. In the ED, her doctor told her that although he would order a scan, there was no way she had a PE because after all, a clinician’s judgement is the best diagnostic tool. His clinician’s judgment must have a NPV of <100% as she indeed did have a PE, requiring months of management.

Despite being in a course where so much emphasis is placed on us becoming non-judgmental, non-biased doctors, as a medical student I often feel the need to hide what I study when visiting a medical professional. It seems that my answer to ‘what is your occupation’ somehow automatically leads to a number one DDx of hypochondria.

“Despite being in a course where so much emphasis is placed on us becoming non-judgmental, non-biased doctors, as a medical student I often feel the need to hide what I study when visiting a medical professional”

In my third year of medical school, I slowly became more and more convinced something was wrong with me. What seemed to come so easily to everyone else seemed near impossible. I couldn’t comprehend how my peers were keeping up with matrix conditions when I couldn’t seem to even start. Forcing myself out of bed on a Wednesday morning felt like torture, enduring a lecture I felt I would never be able to take in the same way as the people sitting around me.

I had the overwhelming sense that I would never be able to reach my goals in medicine- despite a genuine drive and passion to do so. With this constantly in the back of my mind, the days got progressively harder, and the idea of going into hospital would fill me with dread. The upside to all of this was it was great learning for depression and anxiety in 4^th year psych. The downside, I suppose, was the depression and anxiety.

I went back to the second GP, the one who had listened to me stress about my heart murmur, and who had at the time told me that “even as a medical student I deserve to have all my concerns listened to and investigated”. He gave me a referral to a psychiatrist half-way through third year. But it took me another year on top of this to even book an appointment. The constant med-student jokes and dismissals had so deeply damaged my confidence that I convinced myself I was making it all up. Surely everyone feels like this. You’re being dramatic. Stop looking for excuses to not study. It’s near impossible to trust your own sense of judgement when it feels the whole world disagrees. Two separate psychologists told me I just needed to put less pressure on myself. I felt no one was really listening. Was it unreasonable to want to be able to listen to just one lecture? To finish even one matrix condition?

Midway through my 4^th year, I was diagnosed with ADHD. Now that it’s being treated, the idea that I had convinced myself I was making it up is diabolical. Currently, I live a life unrecognisable to my past one. I feel equipped and motivated to face the infrequent challenges that may come up during any given day. Fighting paralysing anxiety just to get out of bed used to be a daily challenge I accepted as normal.

“Fighting paralysing anxiety just to get out of bed used to be a daily challenge I accepted as normal”

Mostly things are great, but I still come across gaps in my knowledge, clinical skills that I never learnt, and wonder what could have been if I’d gotten that diagnosis a year earlier. Or two. Not a particularly productive train of thought, but it certainly makes me want to talk about it in case someone out there is feeling the way I was. Or even if it’s not you, but your friend, or someone in the year below. They teach us about different types of bias, so let’s not forget about this medical student diagnostic dilemma.

Because even as medical student we deserve to have our concerns listened to and investigated.

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If you are feeling anxious or worried about yourself or a friend, please reach out to:

– A trusted support person, friend or mentor

– MUMUS representatives for your year level

– MUMUS Community and Wellbeing

– University support [available to metropolitan, rural, & international students] – philippa.corby@monash.edu, jodie.vickers@monash.edu, or call ‘1300 STUDENT’ (1300 788 336)