Maria Phalime's Postmortem: The Doctor who walked away

Prof. David Sowden reviews Postmortem – the Doctor who walked away by Maria Phalime. 

This was originally planned as a double book review of On the Move – a life by Oliver Sacks and Postmortem – the Doctor who walked away by Maria Phalime. It was to be a comparison of a medical career that by any judge was a resounding success, despite obstacles and one that might have been considered to be not, potentially because of obstacles. However, in the light of recent decisions reached by Jeremy Hunt as Secretary of State (interestingly decisions that the Health and Social Care Act state are no longer the business of Ministers but rather NHS England and NHS Employers) with respect to the junior doctors contract, I thought it more timely to look only at the book by Maria Phalime. At first glance there seems little connection between the book and current events, but it is only a small step from looking at Maria’s position to appreciating how easily junior doctors can view their new professional working life as untenable or unacceptable, and to have a sense of being so little valued as to make it pointless to continue with their career or at least to continue with their career in their country of birth/graduation. It seems to me that Jeremy Hunt has placed the whole NHS at risk on the basis of political dogma (some vague but unexplained and evidentially unjustified concept of a “24 hour NHS”) and the belief that junior doctors, in particular, will not walk away from careers in the NHS. The alternative possibility, that the Government has sought to undermine the publically funded NHS by this measure so that they can implement an accelerated programme of privatisation, is almost too grim to contemplate; and in politics, cock up is more likely than conspiracy. Before commencing this review I must make a confession – whilst I am retired from clinical practice I still think of myself as a “doctor”. I hasten to add that doesn’t mean I still try to diagnose others’ illnesses or prescribe, but my mind set still resonates to that of a clinician, and I still find medical issues absorbing in a way that many other issues aren’t. Indeed I’ve often likened being a doctor to a stick of confectionary rock – cut me in half and you will see “doctor” written throughout. I’m not sure I expected this to happen when I started in medicine but I know from colleagues it is far from unique, and of course explains why some doctors just keep practicing until they drop. Though I strongly suspect many of these are in denial, saying their patients need them when in fact it is they that need their patients. So in that context, whilst I can, to an extent, grasp intellectually why someone might “turn their back on medicine”, at an emotional level I struggle. “If not a doctor – what??” Maria Phalime’s book is a well written attempt to look at the issues that might cause a doctor to stop being a doctor – it has the advantage that it is written about a health care system that is partly alien to the one most of us in the UK will be familiar with. So, initially, at least it all feels a bit, and consequently comfortably, distant, and doesn’t threaten too many assumptions but I would be surprised if, like me, you don’t see the universality of the issues raised; they are just an order of magnitude worse in SA. Though perhaps not that much worse! The policy of Black Economic Empowerment (BEE) has seen the number of black and coloured* [*see below] medical students, and more particularly black and coloured women, increase dramatically in recent times in South Africa. This is in turn radically affecting the racial and gender mix of doctors, not yet at the senior end but certainly at the beginning and middle career points. However, Maria Phalime’s entry to medical school preceded the implementation of this policy and indeed much of her school education took place during the death throes of the pernicious apartheid regime and the rule of the National Party. Thus, despite a relatively privileged black background in Soweto, with a father with a BSc working in a hospital pharmacy (a menial role, it would appear) and a mother trained as a nurse, Maria’s achievement in getting to medical school needs to be seen for what it was – an achievement of mammoth proportions. It was also seen as a wider achievement for the community from which she came and for the nascent black middle class more generally. Though in retrospect maybe those wider expectations weighed more heavily on Maria than she is ready to acknowledge in this book. Particularly, it may have created within her expectations of her ability to change things for the better for her patients and the wider black population, that were unrealistic or overly ambitious for a doctor so early in their career. Mind you, if you can’t attempt to slay dragons when you are young, when can you? Maria’s attempt to complete a thorough examination (though I feel the examination is currently only partial and will require more distance from events to achieve genuine objectivity) of why she completed her medical training but effectively turned her back on a career in medicine, shortly after her 2 year internship (the SA equivalent of Foundation Programme training), is important. They are clearly very important for SA but not just there. Indeed some of the key issues that underpin many of the difficulties that Maria faced in SA are, to some extent at least, similar to those that afflict health care systems across the globe and it is with regret that I note may well have significant implications for England in the context of the recent junior doctor’s dispute and Jeremy Hunt’s seemingly inexplicable and implacable determination to alienate the whole of the medical profession. Maria’s book highlights issues of senior support and mentorship (or the lack of) and work pressures, together with the personal consequences thereof, that whilst extreme should be a concern for all in the medical profession wherever they practice. More importantly though, they should provide lessons for those for whom the protection of the health of the population they serve should be a core and key responsibility – government and Ministers. Trouble is I fear they would probably read this book and miss or misread the key messages it sends to them.

Why are these issues not unique to SA, and universally important?

The initial chapters of Maria’s book is a paean to aspiration and achievement against the odds whilst highlighting how initially fragile are the capabilities of newly qualified doctors. Certainly all medical students must have above average reserves of determination, application and resilience to complete the medical course but even those reserves can be overwhelmed in the initial phases of becoming a doctor in circumstances where the hours are inhuman(e), the welter of human suffering unmanageable, resources poor or absent and in the face of little or no senior support or where the doctor concerned is not supported to come to terms with the day to day professional and personal implications of being a clinician. Maria’s early career saw the birth of the Rainbow Nation, with all its hopes for a bright national future for all South Africa’s people. It is clear that she, in common with most (though not all) of the SA people, was swept along on a tide of expectation of rapid and significant change. Whilst it would be a mistake to see Maria’s book as a testament to the tarnishing of those dreams it is worth noting the troubling continuing undercurrent of racism, misogyny and politically motivated dogma set against the long shadow of the wider social consequences of “colonialism”. All of these together with the gathering spectre of rampant corruption have resulted in a toxic mix that has prevented the implementation of policies that could correct the vast inequities in SA society or at least begin to narrow the gap; of which health is but one part. These problems might be seen as peculiar or particular to SA but the themes they point to are generalisable; and it is troubling to see this book in the context of the seemingly inexplicable debate about universal health care access in the USA and many of the current problems in the NHS across the UK. Good healthcare needs people to deliver it and those people have a right to be treated appropriately; healthcare systems fail where this is ignored or where the pursuit of profit becomes a major driver. Witness the appalling machinations of Big Pharma in the latter regard. I fear that the NHS will shortly pay the price for the former. SA doctors have a relatively traditional medical school education that would be familiar to those who have trained or are training in the UK. In the context of this book and the ensuing issues one might wonder if that training and education is the most appropriate for SA’s healthcare system – Maria doesn’t reflect on this specifically but the key focus on “getting patients well” by investigating and treating them (indeed curing them) does crop up frequently, and as you will see that is part of Maria’s problem. The main difference in SA is during the internship 2 years – one year (so-called community service) of which is usually spent in a public hospital, generally in an isolated, often rural area with very limited facilities and almost exclusively addressing the needs of the black and/or coloured populations. In Maria’s case it was in a township setting; which despite its proximity to Cape Town might just as well have been in a setting many hundreds of miles away. It was here, particularly, that she was confronted with inhuman hours, overflowing emergency rooms, poor or absent resources and little or no support. Unusually, Maria spent her initial year after graduation in Sussex – in retrospect one can’t help but wonder if that experience exacerbated her subsequent problems? Not that there was anything wrong with that period just that it lacked relevance in the context of what was to follow back in SA and that in itself must have created tensions for her and some of these she looks at but her reflections tend to the naif. Her decision to, as she describes it, “turn her back on medicine” was at least partly down to the timing of her community internship during the catastrophic period when the Mbeki administration was denying the link between HIV and AIDs, when the then “Health” (my inverted commas) Minister Dr Manto Tshbalala-Msimang supported Mbeki in attributing AIDS to poverty, bad nourishment and general ill health and by promoting totally unproven herbal regimens and diets to prevent AIDS; leading to her nickname in the newly free SA press, “Dr Beetroot”. Mbeki’s description of her as “one of the pioneer architects of [the] South African public health system” has come to be a defining epitaph for a premiership that promised much but delivered little in the way of real life improvements for much of the black or coloured populations. I know that has a tinge of racism to it but in SA there is a material difference between these populations and they themselves do not, largely, see each group as being anything other than separate. Overall, it is estimated that 350,000 (mainly black) South Africans lost their lives unnecessarily during this period by being denied access to ARV treatment. In retrospect Mbeki’s reluctance to address the real causes of HIV/AIDs had at least some of its roots in colonialism and the caricature of the sexually incontinent, dirty and poor native black population for whom HIV/AIDs was some kind of retribution or rebuke. HIV/AIDs, largely by an accident of environment, has worked its worst in black Africa and mainly sub-Saharan Africa at that and it is possible to see why Mbeki reacted as he did; though perhaps not truly understandable. What is completely understandable is Maria’s complete sense of impotence in the face of a tsunami of human suffering, most of it AIDs related, for which there were literally no tools to treat patients and few to even alleviate suffering. What probably made things worse was Maria’s placement in Khayelitsha (Cape Town) – as she writes :

….. this was a township like I’d grown up in; these were my people. Why did being there feel so alien? The truth was Khayelitsha was nothing like home. Soweto was an established township with ….. houses made of bricks and mortar.”

She describes homes in Soweto with back yards to play in, even fruit trees growing.

I couldn’t imagine any of that happening in Kayelitsha. Where did the children play? What games did they devise to play on the sandy terrain so prone to flooding?”.

Maria again highlights the importance of support and mentorship, though without referring to them directly. Her sense of personal dislocation in a supposedly familiar setting is important and would certainly have been helped with an appropriate support system; even one that was peer based. Her descriptions of work in a clinic at Site B are harrowing. Not because of any attempt by Maria to descend to trite soundbites but rather by virtue of her calm description of what happened. As such a young doctor seeing at least 50 patients a day with no senior oversight or back up, it seems to me no wonder that the stress began to tell. Particularly as so many of the patients (and some staff) were presenting with signs and symptoms of AIDs for whom a positive AIDs test was a guaranteed death sentence; one Maria had to communicate and then try and deal with. Any doctor would find it troubling to have a patient say, on hearing about a positive AIDs test : “ I know what I must do. I must get my affairs in order, and then I will kill myself.” I will let you read the book to find out why (highlighting the importance of bio-psychosocial factors in medical training) but the issues this raises for Maria are not ones one can reasonably expect such a junior doctor to address and then deal with at a personal level – certainly not without help. She writes “Seeing the impact of HIV on a daily basis was often too much to bear.” Frankly, I am surprised at the qualifier “often”. Further, she writes;

Along with anger, frustration became my constant companion…….. I wanted to help but sometimes I felt that my medical training, with its strong emphasis on the scientific method and curative approach, was inadequate to give my patients what they really needed.”

Important echoes here for medical training anywhere, I think. Maria writes tellingly:

...often they came to me not with medical problems but because I was the last resource they could tap to try to improve their lives.”

As Maria nears the end of her community service she exhibits all the classic features of burn out, she has reached the phase where distancing yourself from the pain and distress has become dehumanising. Maria drifts professionally for a bit but finally turns away from medicine, and this part of the book is somewhat unsatisfactory as Maria is too calm and analytical about what must have been a deeply difficult period in her life; maybe just too difficult to describe in any detail? The remainder of the book attempts what Maria refers to as a morbid enquiry, using the analogy of a post-mortem; analysing why people leave medicine. Clearly these are case studies not detailed research projects but their message is as important.This section of the book is only partly successful but will give all practicing clinicians with any responsibility for supervising and supporting junior doctors pause for thought. She certainly appears to have identified a genuinely higher tendency amongst women to leave the medical profession than men in SA, and her exploration of the possible issues is at least worth contemplating even if it does, in part, challenge some of the current perceptions of gender equality. She also quite rightly identifies that the characteristics that make successful medical students may be counterproductive in later professional lives. In conclusion, the book is a surprisingly engaging read and I can see why it won a non-fiction award in SA. The book has its weaknesses and I’m not sure it draws out all the key issues that need addressing by those responsible for commissioning and delivering medical education and training. However, I do think anyone with any level of responsibility for medical students or junior doctors should read it. Had I read it when I was working I would have been more forthright in some of my assertions about selection to medical school and the nature of the curriculum, and the construction of key aspects of initial postgraduate medical training. The one thing I can guarantee you will feel at the end of the book is a hope that Maria’s remaining career is a successful one and that perhaps she will turn back to medicine; she would be an asset in any healthcare system.

Postmortem – the Doctor who walked away. Maria Phalime. Tafelberg. ISBN 978-0-624-05760-4

*Despite attempts to address the adverse impact of apartheid on various racial/ethnic groups the terminology of that period still holds sway domestically in South Africa. The term “black" is reserved for those people of colour whose racial background is generally that of one of the traditional tribal groups of Southern Africa e.g. Xhosa, Zulu, Setswana etc. It now also encompasses black African people from other sub-Saharan countries (e.g. Zimbabwe, Zambia, Malawi) or tribes as well as the people of Somalia, Ethiopia and Sudan.

Prof. David Sowden

MBChB, FRCGP, FRCOG, FFSEM, FAoME, DCH. Now retired. Formerly : Dean of Post-Graduate Medical Education East Midlands (2000 – 2012) Director of Medical Education England (2008/09 and 2012)