Volume 196 - Issue 11
It’s more than the presenting complaint
Author: Marianne E Jauncey
Med J Aust 2012; 196 (11): 708. || doi: 10.5694/mja11.11393
Published online: 18 June 2012
Published online: 18 June 2012
Work, as well as life, can lead to surprising placesIf someone had suggested in my medical student days that I would end up working where I do, I would have laughed. But, no one knows where experiences, conversations and opportunities might lead.
Like many idealistic medical students, I did electives in areas of need. My first was in north-east Arnhem Land. Returning to lectures, I remember ...
Work, as well as life, can lead to surprising places
If someone had suggested in my medical student days that I would end up working where I do, I would have laughed. But, no one knows where experiences, conversations and opportunities might lead.
Like many idealistic medical students, I did electives in areas of need. My first was in north-east Arnhem Land. Returning to lectures, I remember hearing about Sydenham’s chorea and the major and minor Jones criteria for rheumatic fever. To this was added: “but you won’t see that in Australia”. I had seen two separate cases of Sydenham’s chorea in the hospital in Nhulunbuy just the week before. I recalled the other things I had also seen in that part of Australia — malnourished children and houses without running water or electricity. That elective was a chance to see, first hand, that the social determinants of health really do matter. It planted in me the first seeds of an interest in public health.
My second long elective was in a small town in Zambia. Most patients had tuberculosis, malaria, HIV/AIDS or all three. The hospital had scant facilities, and our only postoperative pain relief was paracetamol. Patients underwent surgery on ketamine, often moving and howling throughout. A young girl — an AIDS orphan — had apparently fallen in a fire after a seizure, and had sustained deep burns to much of her body, and never spoke. After many months of painful recovery, she finally left the hospital in the care of her aunt. She returned the next day. We learned that her aunt, again, had poured petrol over her and set her alight — too many mouths to feed. The girl died a short time later. Her problem had never been just the burns.
I spent some years after I graduated trying to make sense of what I had seen, wanting to address patient issues beyond the “presenting complaint”. Then, I saw a job advertisement that said: “flexible and eclectic approach needed to work with vulnerable populations in Kings Cross”. It sounded interesting. The receptionist asked me to provide the first three letters only of my surname on a form. Some minutes and a fascinating conversation later, she realised I wasn’t, in fact, a new sex worker presenting for a sexual health screen, and took me upstairs for my job interview. It struck me that she didn’t apologise. Mistaking someone for a sex worker in the context of this clinic was simply an easy mistake to make.
During my early days in Sydney’s Kings Cross, I wondered if I’d ever learn the lingo of “picks”, “fits” or “dirty shots”. I remember one young woman who hadn’t slept for some days, her mental health disturbed by the large quantities of cocaine she was using. She was working in the sex industry to support her habit, had picked at her face and arms until they bled, and pulled out most of her hair. She couldn’t have weighed more than 40 kg. I felt very naive as she, eating a bag of no-frills liquorice allsorts, berated me. She said that her mother had been “a junkie whore who lived and died in Kings Cross” and that she was too. She had first been injected at the age of 11 years in order that she have sex for money. As we began the consultation, she said, “Don’t bother trying to help me — I’d be better off dead”. My immediate reaction (of which I am still ashamed) was to wonder if she was, indeed, right.
Through working in Kings Cross and studying public health, I learned that the type of medicine I wanted to practise was one that considers the social context of peoples’ lives, and aims to help patients on their own terms, and not mine. Perhaps this is the basis of all effective clinical practice. However, I have also seen medicine that plays out to a script of, “this person is difficult and contrary, I know they won’t do what I tell them, they have caused their own distress, and they are not worth my time”.
Fast-forward to today and my current position as a public health physician and Medical Director of Australia’s only supervised injecting facility, located in Kings Cross. This service sees people often ignored or actively rejected by the rest of society. I hope that I’ve augmented my idealism with some pragmatism and broader understanding. I no longer expect simple answers for the people or situations I see. But nor do I feel pessimism. Reaching out to marginalised populations, near and far, is worthwhile. We all share the same complex, confusing and, at times, confronting world.
And the woman eating liquorice allsorts? The last time I saw her, she had a full head of hair and was reading The catcher in the rye1 while waiting to be given her methadone dose, and leading, for a time at least, a life she perhaps never thought she could.