Fear Not.

* This post is potentially offensive.

 

How far would you go for standing up for what you believe in?

I guess, that is the question.

I shouldn’t have been surprised. After all, it’s happened before, time and again. While I work well in creative environments and thrive on fluid energy, I often find myself sticking out like a sore thumb as a misfit in most structured organizations.

So I got into trouble again.

I should have seen it coming.

How far would you go to stand up for what you believe in? How much would you allow yourself to suffer for it? And would the magnitude of the suffering play a part in determining how firmly you held on to your beliefs? Are some values more worth holding on to? Are some things simply too small to fight for, even though the values that they stand for may not?

Or are all ideals equal. And worth fighting for.

That is the question.

He was a big guy, three times my size. But with his tone of voice and impassioned gesturing, he seemed to tower over me like a giant. “What’s your problem?! Why can’t you just do it?” The bellowing voice was loud, angry, broadcasting its vehemence with great power . His face was puffed up, and I knew everyone was staring at us.

“Look, I don’t understand. Why can’t you just do it?!”

I stood there, silently, feeling very traumatized and at peace, all at the same time. I was traumatized, because his outburst was completely unexpected but at peace, because I knew my conscience was clear. I was bewildered- I just didn’t understand what had caused a reaction of such colossal magnitude.

“Why could’t you just do it?!”

But I couldn’t.

Before I started work in my surgical rotation 3 weeks ago, my friends had warned me before: whether you do General surgery or orthopaedics, as long as it’s as surgical rotation where you’ll be working under results-driven surgeons, do what it takes to make them happy. Follow orders. Do as you’re told. And make your bosses happy. No matter if they shout expletives at you. That’s common- just apologize. Just, make your bosses at every single rung of the hierarchical ladder happy, and everyone goes to work and goes home happy.

I guess I rocked the boat.

In surgery, hierarchies frame and hold the institution like pillars hold a house. The House Officer (junior doctor) reports to the Medical Officer who reports to the Registrar who then reports to the Associate Consultant who reports to the Consultant or Senior Consultant. The Senior Consultant makes a decision and orders are meant to be carried out. No questions asked.

Having just completed 4-month rotation in General Medicine, where seniors encourage inquisitive thinking and constructive questioning, I was thick enough not to realize how vastly different the surgical atmosphere would be.

Don’t ask questions.

But I like asking questions. I can’t help it.

Over the past 4 months, working in the previous department at my previous hospital has been an amazing experience. Being under some of the most inspiring physicians I know has helped me to gain confidence in independent decision-making, taught me to question conventional practice and has encouraged me to approach seniors to ask questions, simply because there was such a strong culture of learning and teaching.

Ask questions. Think. Question authority. Be a thinking doctor.

That was what I was taught.

I didn’t realize, however, that being flung from Internal medicine into Orthopaedics, also meant flinging those ideals and values away.

I learnt the hard way, that surgical departments are run like the army. You obey. You don’t ask questions. You follow commands and you carry them out swiftly. There is no room for error. There is only precision, speed and clarity. No questions asked.

I was told to write a referral letter for a patient to an Endocrinologist to look into her diabetic issues.

I had written up the referral and was about to send it off when I realized… that she didn’t have diabetic issues. Her blood sugar was between 5 to 9, her HbA1C ( a marker of sugar control) was 6.4%. In my previous hospital, I had been taught very strictly, not to make unnecessary referrals- not only do they add unnecessary cost to the patient, they tax the hospital system unnecessarily and create unnecessary work for everyone. Yet, it happens- everyday it happens, simply because in a litigious society, every doctor wants to have his or her back covered.

That day, I explained why I didn’t send the referral off. I wasn’t sure what I was referring the patient for, since she had stellar glucose control. Instead, I printed out the criteria for impaired fasting sugar to compare it against her blood results.

In my previous hospital, my senior consultant ( an extremely benevolent man who worked previously as a pastor as well) would have taken that opportunity to encourage and commend me, and use it as a teaching opportunity. We would have had a spontaneous half-hour discussion on the diagnostic criteria of diabetes, and when we ought to make referrals. We would have discussed with great enthusiasm the latest updates on diabetic management.

But not here.

I was tuning into the wrong channel and cruising at a completely different frequency altogether.

There was a palpable sense of disequilibrium when that happened. I had just overturned the immutable laws of the surgical universe and caused a disalignment of the cosmos. The senior consultant was amused. He’d probably not seen a House Officer suggest something other than his commands before. But he saw my point, he was amused with me and he let it go.

“All right,” he said, “as long as she doesn’t have diabetes.”

But my other senior wouldn’t let me forget it.

 “Look, I don’t care if you’re right. I don’t care if you took the effort to look up the criteria for diabetes. That’s not the issue, okay?”

The issue was, I didn’t do as I was told. I had questioned authority.

Even though I had meant no harm, and there was not a hint of defiance or pride or disdain in what I shared. I genuinely stated my point of view as I would have in my previous department at my previous hospital.

So you can imagine how absolutely bewildered and thrown off I was when the torpedo ran into me.

Was it worth it? Would sending off an unnecessary referral kill me? Was it that difficult? Would it kill me to make everyone in the team happy?

No.

The truth is, not sending that referral off that day and not following the orders caused me much more trouble in return. In a place where hierarchy is worshipped, I must have appeared no doubt, even with a soft tone of voice and a polite question, like some sort of a rogue. 

Some friends who heard this story were appalled at how I was lambasted at. Some who were more seasoned simply shrugged- they had expected it. Other senior doctors from non-surgical specialties whom I shared this with stood with me in solidarity, appraising the fact that I was practicing good medicine, and not “defensive” medicine where one refers to another specialty simply for the sake of “feeling assured”.

But life at work, in a way, has been hellish since that episode.

Was it worth it?

Maybe not.

But whatever it is, I did learn one thing.

That there is a price to pay for standing for one’s beliefs. It means sacrificing something- comfort, ease or convenience. And yes, it can often feel very, very stupid. But if it’s the right thing to do, then holding onto what you believe in in the face of ridicule, hurt and insult can build your resilience in ways you least expect. In a strange way, that sort of suffering preserves your dignity and strengthens your character.

I never regretted not sending that referral. The thing is, I would never  be able to justify why I made that referral, and I guess the crucial point is, I couldn’t allow myself to do so out of fear.

In the large scale of things, it really was a small incident. But it was important to me because it helped me to see how much fear can control us. We can be junior doctors controlled by fear, running behind the hems of senior doctors who wear their majestic cloaks around the hospital wards, or we can be junior doctors who choose to practice medicine by being compelled by love, compassion and good evidence-based judgement.

So even though I’m staying back nearly everyday till 9pm from starting work at 6am, even though it feels like I’m being put down and told off everyday, even though external forces are trying to mould me to become a slave instead of a growing being, I hold onto my faith that I live and I work and I breathe for my patients and for God, and I work for Him, not for man. I work for excellence, and not because of fear.

100-hour work weeks don’t seem so bad anymore when one realizes who one’s Boss truly is.

Sometimes, one can be stuck in sticky situations. What do you do when your senior who doesn’t show up for regular morning meeting ask you to sign his attendance for him? Would it kill you to do so? Won’t it make your working relationship with him far easier?

But is it the right thing to do.

It’s not under my control that I’m stuck with some seniors whose words cut like knives. In surgical departments, this torment is part of the ritualistic baptism of fire that is “supposed” to help us “toughen up”. (Not that I agree with it.) But it’s under my control to make a stand for what I believe in, to ask when I don’t understand, to question when I’m not sure.

Because ironically, I think it is the unquestioning doctor who can be most dangerous to patients’ care.

Because we have a choice, to succumb to the pressures around us, or to make a stand for what is right. And to me, that means asking when one is not sure. That means pursuing knowledge and good medical practice, and not administering healthcare out of fear. Because that is what I was taught and that is what I believe in.

So even though many tears were shed over that episode, even though I’ve been leaving hospital at unearthly hours every day, it’s okay.

Because at the end of the day, we need to know who we truly live and work for.

Of late, a friend confided in me, “Jia, this working environment is horrible, there’s no teaching or learning culture in this place. There is only fear and intimidation. What can we do to make a difference?”

“Stand up for what we believe in. Live, love and work as if we are working for God and not for man,” I said.  “Because we can make a difference, just by being who we are.”

 

“Serve wholeheartedly,

as if you were serving God, not men.”

-Ephesians 6:7

 

“Who is going to harm you if you are eager to do good? 

 But even if you should suffer for what is right, you are blessed….

Do not fear their threats; do not be frightened.

 But in your hearts revere God.”

 -1 Peter 3