Reflection on a year working at Mseleni Hospital, South Africa

By Patrick Hart

Applying to work in South Africa means long months of sending and receiving paperwork. Most people wonder at some point whether it will ever happen. As I was waiting for mine I sometimes imagined how it might go when/if I finally made it. In my mind, it was one of two ways. Either things would fairly rapidly fall apart and I would have to admit defeat, come home and perhaps hide out at my brother’s house sending fake updates to family and friends to disguise my shame. Or I would master the whole affair and become some impossibly competent doctor stereotype. For some reason I didn’t dwell too long on a much more realistic scenario, and the one that became the reality – that I would cope.

During that year in South Africa I had the best, most meaningful, most satisfying days of my career so far. I also had the worst, the most despairing and the most traumatic. I worked harder than I have ever worked. Not because I had to but because I wanted to. I believe I learned more than any other year of my life to date, including the toddler phase when you are learning to walk and talk and scribble with crayons all at the same time. I gained affection for people and places so much so that it already wrenches at me to think of what I have left behind. But most of all that year I coped. 

I don’t think of myself as a coper generally. I spent my foundation years mainly panicking and calling the registrar. This was undoubtedly the best option for most of my patients. I suppose that’s part of the reason I wanted to go to South Africa, to see if I could cope. And of course I did. Humans mostly do, when faced with adversity. It’s almost a universal law. When things get tough we all pull together and cope. It’s a law too, at least in the west, that we are nearly always amazed with ourselves when we do.

So how did I, the non-coper, pull off this coping? At first it was mostly through ignorance at what an inadequate job I was doing. Those unknown unknowns shielded me from the realisation that I wasn’t coping. Suspecting this might be the case I set about learning as much as possible, starting with how to manage an antenatal ward, deliveries, caesarian sections and running an HIV clinic. As I worked and read and practised, inevitably the realisation came that I had been doing it all wrong. Furthermore I had a long way to go in learning to do it right.

So then came the second stage of coping, in which I worked harder. Though not normally work-shy, my energy and diligence during this period surprised me and anyone who knew me. I was buoyed up by the immediacy I felt. If I didn’t do it, then it would simply go undone. There was undoubtedly an element of hubris involved but I really felt indispensable, perhaps for the first time in my life. So I did the hard work willingly, and for a while at least this felt like a way to cope.

I have never experienced true burnout but after spending 6 months tackling every problem by throwing more energy at it I was definitely on the way. I remember one on-call I was on my way to bed in the early hours after a caesarian. I had been awake for a very long time. It occurred to me that I had walked into theatre and operated without saying much of anything to the staff or even introducing myself to the patient. I had finished the procedure and walked out. My overwhelming desire for sleep had overruled a habit of courtesy that was previously second nature. Later I recalled a comment from a colleague some years earlier. She said when doctors burn out the last thing to go is clinical competence. Lost much sooner is compassion. Many of my colleagues seemed hardier, able to endure sleeplessness and stress and still maintain their compassion. But not me, I resolved to do less, sleep more, eat regular meals and get some exercise. So began the third phase of coping.

Medicine has always involved hardship, wherever or whenever you look, and to my senior colleagues in the UK the above account may well sound familiar. And of course my South African colleagues are mostly still where I left them, still coping. Everybody is doing it every day. So why do we find it so amazing?

If you have never seen Saturn through a telescope then I strongly recommend that you have a look if you get the chance. Everybody knows what Saturn looks like and everybody knows it is to be found in the sky; Yet when you see it for the first time rings and all, just up there, the feeling is one of disbelief. As you are digesting this feeling you might be struck by it’s ridiculousness.  It’s fascinating how we can be so consistently amazed by things that have always been right in front of us.

“It’s not rocket science”