Maria Phalime's Postmortem: The Doctor who walked away
02 March 2016
Prof. David Sowden reviews Postmortem – the Doctor who walked away by Maria Phalime.


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.
….. 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.The term coloured specifically refers to peoples of mixed race origin, including the children and descendants of black and white people and those of Malay descent amongst others. The coloured population is almost, but not quite, unique to South Africa but the sheer size of the coloured population is unique.
The black and coloured populations remain largely separate and do not mix to a great extent; though times are changing.
The historic native people of the Western Cape (the Khooisan and San people) sit in a bit of a no-mans land in this regard. Depending on circumstances, too complicated to detail here, they can be considered coloured, black or both.
People of Indian descent are most usually termed “coloured” too, but not universally so. These distinctions may appear “racist” to an UK audience but are an accepted feature of South African domestic politics; though some are now beginning to question the assumptions that underpin the terminology.