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A cog in the machine

Cate Swannell
Med J Aust || doi: 10.5694/mja17.1704C1
Published online: 17 April 2017

Dr Sam Brophy-Williams is an advanced paediatrics trainee and is just back in Australia after 6 months in Afghanistan with Médecins Sans Frontières …

DR SAM Brophy-Williams is just 31 and still has 18 months to go before he finishes his advanced training in paediatrics, but he’s already gathered experiences other doctors his age can only dream about.

He is just back from a 6-month posting to a maternity hospital in Kabul, the capital of Aghanistan, courtesy of Médecins Sans Frontières. Located in the poorer, western outskirts of Kabul, the hospital averages around 50 deliveries a day, about three times as many as a tertiary maternity hospital in Australia.

Dr Brophy-Williams was the only non-Afghani in the group of eight on-staff paediatricians.

“The area the hospital was in was very under-serviced,” he tells the MJA. “There wasn’t anywhere else people could go, for a population of about a million people, for free maternity care, particularly high-quality maternity care where you could get caesarean sections and those sort of life-saving things.”

Kabul has been one of the world’s hot spots for a long time, but for Dr Brophy-Williams and his MSF colleagues, who lived together in a house about 400 metres from the hospital, it didn’t feel like a dangerous place.

“Part of that, though, was because we lived in a strange sort of bubble,” he says. “Physically, and socially as well. Where we were was unique because we could actually walk between the house and the hospital which was a few hundred metres of freedom I absolutely cherished.”

Dr Brophy-Williams was always aware, however, that things weren’t always easy for his Afghani colleagues. “They faced a lot more danger than I did, just trying to get home from work each afternoon,” he says. “There were quite a few incidents in Kabul – kidnappings and bombings – while I was there. But I never felt that I personally, or MSF as an organisation, were ever targeted. So, the risk was largely one of being in the wrong place at the wrong time.

“I could tell you a lot about our little district, but I couldn’t tell you anything about the Friday night social scene in the middle of Kabul.”

As for the clinical experience he picked up in Kabul, it was an invaluable learning opportunity, he says.

“My job was in part clinical, and in part training, teaching and supervising and managing the department. The babies that we admitted to our newborn unit came with much the same problems that babies admitted into neonatal units in Australia have, so the biggest problems were prematurity, low birth weight … neonatal sepsis, jaundice.

“There was a subset of much rarer conditions which usually in Australia we have some antenatal hint at, but in Afghanistan where there is very limited antenatal care, not many ultrasounds, not many blood tests, they come as a bit of a surprise.

“We had far fewer investigations and far fewer treatments at our fingertips [in Afghanistan], so you come to rely a lot more on your clinical acumen rather than lab tests, and you come to rely a lot more on coming up with some creative solutions.”

Intimidating? Certainly, but for Dr Brophy-Williams it was challenging and enjoyable.

“It is challenging – not just the clinical part of it but also the non-clinical part of the work and non-work part of life. But it’s certainly something I’ve walked away from enriched and wanting to go back again.”

Coming back to the reality of life in Australia as a trainee, albeit an advanced one, after 6 months of great responsibility, is a challenge in and of itself. Dr Brophy-Williams is now working and training at Royal Darwin Hospital.

“It is a change, going from being, not only the paediatrician, but in my case I was usually the most senior medical person in the whole hospital. For a while I was the medical director of the hospital.

“Coming back, I think it very much depends on the mindset with which you approach it. Although I’m really happy with the work I did in Afghanistan and I felt I had expertise to bring to bear, I certainly think I’ve got more to learn … the learning curve is steeper now.

“There’s little point in being resentful or being proud or thinking ‘oh come on I’ve run a whole maternity hospital, I don’t have to do these silly forms’. My mindset is very much actively cultivating this idea of, now’s the time I can really maximise what I can learn, to seek that feedback, to get better.”

“It’s about putting ego aside and realising that the long path towards medical specialisation is there in front of me, and it’s a path we’re all going to have to tread and so … try and look for the opportunities and see it as time to improve the kind of doctor you’re going to end up being.

“That takes away some of the frustration that some people feel [returning from an MSF mission].”

Paediatrics always appealed to Dr Brophy-Williams.

“Partly because I’m a little bit immature and I like to muck around and have fun, and paediatrics gives you a licence to do that. I headed that way and I found that I liked it the further I went so I kept going on that path,” he says.

“Paediatrics is a great career for people who aren’t very good at choosing, like I am. Even at the stage I’m at now in general paediatrics my advanced training could take me from neonatal intensive care to the other end of the spectrum at community developmental paediatrics which is very much about the course of childhood and psychological development.

“A lot of the patients get better and leave hospital, and probably forget all about you and go on and have very normal lives.

“I find that very encouraging – if you intervene early, someone’s whole life trajectory is altered for the better. That inspires and energises me.

“Some of my adult colleagues are dealing with lives towards the end of that life-course trajectory and the changes you make don’t have such a long-lasting effect.”

Dr Brophy-Williams won a John Monash Scholarship in 2012 and spent a year at Harvard Medical School in Boston, earning his Masters in Public Health.

“I’ve always been interested in how the cog that is me fits into the wider medical machine. An appreciation of medicine from the public health point of view is so valuable for clinicians,” he says.

“One of the biggest sources of dissatisfaction that I see among my medical colleagues, is that sense of anonymity, of being a replaceable part in a larger whole, and not really appreciating or seeing how that whole machine works.

“Seeing the health system as a whole gives so much more meaning to the part that I play and the part that all clinicians play in it. It empowers you to change things that aren’t working, to have a voice in how you think clinical medicine should be delivered rather than feeling like a replaceable part in the whole thing.”

Dr Brophy-Williams plans on future MSF missions and says his Afghanistan experience “absolutely” made him a better doctor.

“For a lot of reasons. Firstly, the clinical skills. Second, there’s the managing side of it. And that brings to bear skills that are relevant beyond just the patient in front of you.

“And thirdly there’s the more metaphysical stuff about making you a better doctor through that connection with the rest of the world and with the different ways that people live and the different circumstances people are coming from.

“The broader exposure you can have to that sort of thing, the better you are at interacting with all sorts of people and fundamentally, medicine is a job about interacting and about communication.”

As he told a group of medical students recently, “you don’t have to be in a hurry”.

“Unfortunately, the things that necessitate the existence of MSF and all sort of humanitarian organisations, are not going away overnight.

“That’s heartbreaking to think that no matter what you do in the next few years, there’s still going to be another famine or another earthquake.

“It sounds morbid, but there’s no rush. People who want to get into this sort of thing – it’s about getting yourself into a position where you feel that you’ve got something to contribute rather than just meeting the minimum criteria.”

  • Cate Swannell


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