I’m on the cusp of the ACEM fellowship clinical exam, surrounded by practice OSCE stems, motivating phrases on a white board, and self-critical thoughts about neglected relationships. This milieu is a psychologically provocative one and I find myself reflecting on a particular piece of art by the synthetist painter Paul Gaugin:
D’où Venons Nous / Que Sommes Nous / Où Allons Nous
(Where do we come from / Who are we / Where are we going)
I stumbled into medicine by chance. Despite coming from a medical family, medicine in general had never been part of my life agenda. My father, a rural generalist solo practitioner, discouraged me from medicine for the first two decades of life. After following a crowd into law school post- high-school, I dropped out after one day to begin a stillborn apprenticeship as a chef. The cooking business lasted a year: by chance I read a book by Russian journalist Anna Politkovskaya on the Russian invasion of Chechnya, which was catalytic in reorienting my career aspirations. Medicine became a craft with a tangible, portable skillset that could be exercised in the spirit of social justice. I was able to piggyback off my high-school grades into medical school and muddle my way though, collecting a handful of mentors along the way. A tragic aside – Politokovskaya was murdered in my second year of medicine – the murder motivated by her social justice advocacy through journalism.
Anna Politkovskaya, 1958 – 2006 – an unfinished life
Patients often ask me if I am married. I usually make some nonchalant self-assured remark about having a couple of children and a mistress – two kelpies and the emergency department. Beneath the glib attempt to put patients at ease, there is a troublesome reality – without imposing boundaries on medicine, it could easily come to define my life. I am thankfully able to rein it in by fostering a broader perspective on life, society, the environment and the cosmos.
Truth be told, I am far from self-assured. I generally feel like a confused albeit cultured ape. I take pride in honing my clinical credibility and delivering care to vulnerable, anxious and wounded fellow primates. At the same time, I feel ashamed by waste, pollution and potential harm I do to the planet and to patients, as a cog in the enormous wheel of the medical industrial complex. I feel uncomfortable that this technology driven-wheel tends to grind for the haves at the expense of the have-nots. I feel no satisfaction spending public money on exercise stress tests (up to 24 false positives for every 1 true positive in women), or other no-value investigations, therapies or procedures. At the same time, I feel immense satisfaction when I connect with patients and provide explanation, reassurance or comfort. These dilemmas pervade the rest of my life as well. Should I respond to climate change by not having children? Or should I not worry about the planet since we’re just a pale blue dot anyway? Accepting the uncertainty of existence makes accepting uncertainty in medicine much easier.
The blueish-white speck of Earth with 6 billion kilometres of perspective. Voyager 1, 1990
Training in emergency medicine has been a wonderful journey. The cobbles are now more familiar than when I was a truant medical student, however I’m not sure familiarity is where my future lies. I’ve no doubt emergency medicine could be harmonized within the context of the cosmos, but the model of health care in the industrially developed world seems to stray farther and farther from the reasons why I took up the stethoscope in the first place (ultrasound actually; I don’t own a stethoscope).
Paul Gaugin gave up a career as a stockbroker to learn art and paint his way around the world. Perhaps I too may choose a path less worn. Thus far, emergency medicine has gifted me with instruments necessary to manage complexity, uncertainty, stress, conflict and high emotion. Ultimately, I know that wherever I chose to navigate my future, be it in EM or art, I’m well equipped to sail around the shoals and find safe harbour.
Thomas Brough, May 2018