By Dr Owen Wiese
I remember very clearly an incident during my community service, when I walked into the trauma unit at a day hospital in Cape Town one morning and found a patient lying on the trolley, bleeding profusely from a knife wound. I picked up the patient’s file and read: stab wound to the chest — assault. This was after I had already spent the entire weekend at the hospital, working two full night shifts from 7pm to 7am attending to similar cases.
Holding the file in my hands I wondered what on earth I was doing there. This had become a pattern, day in and day out. After enduring this relentless onslaught for months on end, I was close to breaking point. It was at that point that I decided I wanted out as soon as my year of community service was over. Five months later I exited through the dusty swinging doors of the day hospital and vowed never to return to state medicine.
Sometimes I think I could have coped if I had support from the hospital, or if it were just run better. Simply employing more doctors would have helped significantly but, regardless of how busy the hospital was, management would always put only one physician in the trauma unit during the day, and two at night. I often saw more than 100 patients during a single night. If you consider that each patient needs assessment, treatment and referral, and the time it takes to perform all of this, it’s blatantly obvious that none of them get the care they need.
A study published in The Joint Commission Journal on Quality and Patient Safety (2008) found that, when working overnight, on-call junior doctors have twice as many attentional failures and commit 36% more serious medical errors. They also report making 300% more fatigue-related medical errors, often leading to patients’ death.
If you tried to speak up and ask for help with the patient load, management’s reaction would always be, “What do you expect us to do?” They’d tell us to tell the patients to make another appointment, or to go to the trauma unit that night when there were two doctors on call. They were not interested in finding solutions – they had given up caring long ago and had no interest in the quality of medicine in their facilities as long as the casualties and out-patient departments were cleared at the end of the day.
But even when we had the time, we rarely had the tools we needed. Another source of stress is the constant shortage of basic equipment such as drip needles, or basic meds for hypertension or diabetes. The hospital’s poorly-stocked pharmacy would have an “out of stock” note where the life-saving meds would be, which meant I had to write a private script for a person who could hardly afford a loaf of bread. Of course they weren’t going to buy it (some 80% of SA’s population don’t have medical insurance), which meant in a week’s time they’d be back with even worse symptoms, and we still wouldn’t have the meds.
What also got me down is the lack of self-care and education among regular patients. Because you have to see so many people during a shift, there is no time to educate them about their disease. This means that they don’t continue taking their medication or make changes to their lifestyle, and become a chronic burden on state health.
Then there are the dangers to the doctors themselves. Doctors in South African government hospitals are frequently exposed to tuberculosis, and I knew of five doctors who were being treated for TB while I worked for the government. Needle-stick injuries are also extremely common, especially in the trauma unit where we’d have to deal with aggressive patients who are often still on drugs. At one stage, four of my colleagues were taking anti-retroviral medicines (ARVs) following needle-stick injuries. Taking ARVs is no walk in the park – most people who take them become very sick, but taking sick leave is not an option.
Should one of the doctors become ill, there is no backup for the remaining doctors who have to take on the absent doctor’s load. Doctors know this, so most come to work anyway and work through their illness, putting themselves and patients at risk.
The hopelessness of the situation – long hours, not being able to help people who don’t want to help themselves and a total lack of support from the hospital’s management made me feel totally useless. For a doctor, this is the worst place to be.
A study published in the SA Journal of Psychiatry in 2012 showed that more than half of the doctors who participated in the study usually saw 30 to 50 patients a day. Of the 67 doctors in the study, 51% were found to be stressed and 27% morbidly stressed.
He found that stress and burnout are common among SA healthcare professionals, and while work-related stress rates among the general working population averages 18%, among doctors the rate is around 28%.
It’s no wonder I became one of those statistics, though it may be that it is mainly the doctors who care who burn out. The dilapidated passageways of government hospitals and clinics all over the country are filled with doctors who stopped caring a long time ago and stay in their jobs because it’s easy, or because they are aiming for specialist positions, and rocking the boat could ruin their chances.
When I realised I couldn’t do this any longer without losing all sense of humanity, I succumbed to emotional exhaustion, a deep sense of depersonalisation and an enormous feeling that I had accomplished absolutely nothing since the day I first set foot in the hospital – full of hope, and eager to start helping people.
There are major concerns regarding the exodus of doctors from South Africa, yet the government does nothing to keep them. Many other countries offer better salaries, a more favourable working environment and a sense of partnership. I can’t remember how often I heard my colleagues say: “Just get through your internship and community service and then leave the country.”
The only answer the authorities are apparently capable of is: “We are a third world country with a critical shortage of doctors due to the increasing burden of disease, yet we accept that the doctors we train leave the country because we have a solution: we import foreign trained doctors.” This is a slap in the face of every doctor ever trained in South Africa – because it shows so clearly that the government just doesn’t care enough to improve working conditions for doctors.
I’m not sure if medicine in our country can still be considered a good career choice. Why would anyone want to become a doctor if it is a merciless struggle just to get through a working day?
If something is not done, there will be no South Africa-trained doctors left in the country, and hospitals and clinics will be manned by foreign doctors who are unable to communicate with their patients due to language and cultural differences – while other nations will be served by some of the best trained doctors in the world. And, at the end of the day, the people who are losing out the most are the people we’re aiming to serve – the patients.
Dr Owen Wiese is Health24’s resident doctor and holds degrees in medicine and science from the University of Stellenbosch. He worked in the government sector before joining Health24 as resident doctor. After graduating from Stellenbosch University with additional qualifications in biochemistry and physiology he developed a keen interest in providing medical information through the media. Dr Owen is based in Cape Town.