Taboo

I've written plenty about the conversations we are not having. About the art of communication and important conversations. About death.  About race. But there are so many things we don't talk about as a society. Money - how much we are paid, how much we owe, how we're (almost) all struggling to get by. Bullying and harassment - how it happens to so many of us, so often, without any real form of recourse. Inequality - how some of us benefit from it and do little to change the status quo. Sexual health - about how it's more than STI checks and occasional ads about talking to your doctor. Menstruation - really, at all. Love - how it's so easy to be broken. And burnt out - how it happens to all of us.

Why do we not talk about these things? Is it this fear of being vulnerable? About being found out as weird or unusual? About being judged for being different, even though we are all so similar in our oddities? There are very few things that are inherently bad to think or discuss. Opinions are formed by the world we live in and our reactions to local events. So why do we not talk about so much that we all consider by ourselves, in the quiet space of our own minds?

Recently, in a fit of an early mid-life crisis, I was looking at jobs (any job) in the city I'd most want to live in. Curiously, where Australian jobs list approximate salaries, this nation did not list any sort of guide as to wages. Would I, in a reckless move, be able to live the life to which I have become accustomed? With no guide, the job could offer $30K or $300K and I'd be none the wiser. In my present profession as a junior doctor, our wages are clearly listed in an agreement. There is no hidden catch. It's not hard, amongst colleagues, to talk about how much we earn because the difference between us is indicative of level, overtime and odd-hours worked. By having an industry agreement, the taboo of talking about wages has disappeared. There is little in the way of gender pay gap in this system, though there is a state-based gap. And so I forget, talking to friends and new acquaintances in different fields, that it is impolite to ask how much they earn. I'm often curious - what do different professions pay for different skill sets? Why is a talented graphic designer unable to imagine a life on much more than $60 000 but a road work traffic director paid approximately what I earn? Why are artists paid so little for something that requires talent to be honed for years into a much appreciated skill, even though many could be paid more to work in table service at average restaurants? How do our value systems reflect in how much, as a society, we've decided different skills are worth being paid?

I've been bullied. I say this knowing friends have had it much worse; knowing some friends have found the bullying so pervasive and soul-destroying that they decided not to continue on with this precarious thing we call life. I say this knowing that speaking up about bullying is almost unheard of in our profession. People will talk amongst colleagues about those times they suffered but very rarely do we have the capacity to speak up to someone who can change the system. Those people are often the bullies themselves, but more importantly, they are the people who decide our careers. And in this profession, our careers are tantamount to our reason for living. To barred from the career we have fought tooth and nail for, sacrificed family lunches, baby's first steps, loved-one's weddings, our own sleep and well-being for, is unthinkable. It's frightening. And so, disempowered, we continue to quietly complain to our friends but know not how to alter the system. We promise ourselves that we won't be the problem when we "grow up" knowing that the stress of the system may inadvertently make us into the people we would hate to become. Bullying, anecdotally, decreases when people are adequately paid (their overtime), working reasonable hours, able to sleep and spend time with their families, and thus less stressed at work. Our jobs are stressful enough on their own. As many before me have said, being a doctor would be a great career if all we had to do was take care of patients.

Which brings me to how we work. Medicine is, somewhat surprisingly, mostly a profession of calculations and intuition. A series of clinical symptoms (often with some eponymous name), coupled with a set of clinical signs, an array of expected blood results and confirmed with imaging findings leads to a specific diagnosis. The same symptoms without the signs, or without the blood or imaging results, leads us to scratch our heads and often send people home without a particularly helpful diagnosis. "Something viral," we say, or "you have real pain but we have no idea why and it's unlikely to kill you," as if this is reassuring. It won't kill you! Medical school, clinical training and eons of healing history have not prepared us for the work we so often need to do - listen carefully and comfort always.

One of my friends was telling me how, almost invariably, 20-something-year-old patients presenting with a sore throat almost never have a sore throat. They generally present with anxiety over intimate issues, and don't quite know how to tell anybody about their worries. And so, with some digging, treating these patients is about addressing their underlying concerns and giving practical advice to help them. And yet so many others just like these young men may not find such open ears to their true problem, and find themselves at home with some cough syrup and little else for their trouble. Because medicine is taught almost solely as the treatment of illness rather than the preservation and improvement of overall health and well-being, we sometimes forget that we can do more than fix that which is broken.

Finding my feet in urology, I'm often confronted with these taboo topics. How many adult circumcisions have attended the Emergency Department with dehisced wounds only one or two weeks after their surgery? In pain, suffering, the medical culture asks us to be disappointed in their lack of self-reserve and willpower. We sigh and tell them that repairs will be needed, and that the period of abstinence will begin all over again. But who is at fault here? Was there an honest and direct pre-procedure conversation? Did the patient understand? Did we listen attentively? And for all of my elderly men with prostate cancer, for whom anti-androgen therapy is often a mainstay of therapy, we explain the expected loss of libido and gaining of fatigue, but how much do patients understand this? How much should we be discussing the trade-off between a life much longer lived, but without an element of it that may have been integral for five or seven decades, or the alternative? Do we make time and space for these thoughts and discussions? How often do we talk about benefits of suprapubic catheters over indwelling urethral ones because of their ability to maintain a healthy(ier) intimate life rather than talking solely about the infection control and erosion perspectives? And because these topics are so hard for so many to tackle, these important questions do not get asked. Patients perhaps find themselves without answers. Physicians think they are doing their best. But are we?

We ask ourselves and others to love and to love completely without teaching in school or in life about how to be honest with these emotions. We ask for monogamous love forever, forgetting that lives and bodies and situations change, and without a language to tackle these changes. We transition between lovers and carers when one or the other becomes ill or elderly, and forget how to be whatever it was that we were before. We become frustrated in ourselves and throw fits, pushing each other further away while all the while being lonely and wanting to reach out. Why is it that we cannot sit with these thoughts? Sit together with these questions?

I am tired of not talking. Here is my promise to tackle that which is difficult. To start conversations. To be open. To be vulnerable.

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