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Nabil Al Khalisi, co-assistent uit Baghdad, geeft hier zijn ervaringen tijdens zijn eerste maanden in Medinat el Teb ziekenhuis in Baghdad. Een co-assistent is een medisch student die in het ziekenhuis praktijkervaring opdoet.
Being an intern in Iraq is hard, even if you are working in Al Madina Hospital, which for decades has been considered the best hospital in Iraq. The work changed the way I look at things and made me reconsider every detail of my life. It is not about logic or morals, but how you relate to the world around you. I learnt a great deal but not all of it was good. Although this article may read like a catalogue of ills, keep reading as there is a bright side.
On my first day at the hospital a senior colleague told me, “The patient is your first enemy.” I was shocked to hear this in a job that is supposed to be centred on helping patients. But I came to discover that it was at least partially true. Some Iraqi patients have “extraordinary talents” that I might be unable to handle with my limited life experience. They could be mass murderers or death squad members, of which we have many in every neighbourhood, or they could just be disturbed and want to kill you if you mess with them. It made me fear all patients for a while but as time passed I became an expert in diagnosing people’s diseases and also their “talents.” So when a patient with a “talent” comes to me I try to get rid of them by any means possible, even if I do not treat them, so that when an ordinary patient comes to me I can manage them properly and give them more of my time.
When I started, there were 40 young doctors assigned to this hospital, and we soon discovered that our number was way too small, leaving us devastated by the long working hours. I saw my family barely once a week. After two weeks I began to complain, as did everybody else, and we concocted our own strategies to reduce our shifts. We started to handle more patients in the same time so that the total hours per month would halve, but we could not maintain the same efficiency or proficiency. We became more aggressive with patients and more demanding of them. Each one of us had our own set of tactics to escape the workload, which helped us but not the patients. Logically we did the right thing because no one can stand such conditions for too long and eventually we would have lost our health, and our patients would have lost their doctors. Morally, we should have worked harder and harder because these are other people’s lives and we should always do our best. Another factor to add to the equation was the routine. We were meant to leave the ward and sign our names at 8 am and 2 pm—the hospital requirement to satisfy your senior’s bureaucratic needs. There was no similar system to guarantee the patient’s right to adequate health care because there simply were not enough doctors or nurses to do so. The chain of command was so unbalanced that it made us all prefer to stay on the safe side and save ourselves come what may.
Empathy? Sympathy? Compassion? All are nice resonating words that I used to hear and believe in during my study years, but I felt that I would break down within a month if I tried to apply these concepts. It is just that there is only so much pain and sorrow a person can take. It is beyond imagination; real tragedies are going on here, too much killing and violence, too much brutality and ruthlessness that no one can handle alone. I learnt how to sort things out, to try curing the patient but not to feel sorry for him. On my first week I felt sad for every patient. I became so depressed and frustrated that I projected my sadness on to my family and friends and that was pure stupidity. Then I realised that I could overcome this with “apathy”. In the past few years I considered apathy a disease entity but am now reconsidering it as salvation. I cannot care about a patient’s postoperative pain because I have no analgesic at hand but I can care about infection and haemorrhage as I have some antibiotics (although many are missing) and a blood bank (that can barely satisfy a patient’s needs). Most of the time patients complain and say, “You are supposed to be more caring, you do not deserve to be a doctor, you are not human.” They look at things in a narrow scope, they do not see the burden the doctor is bearing but they see only their pain. I have to ignore these comments too.
Patients are very difficult, it seems they are contributing to your failure. They neglect symptoms until they present so late that you can do nothing for them except provide palliative treatment to let them die peacefully. Sometimes they present to you earlier but they do not stick to your instructions or take the drugs you prescribe. Sometimes they just commit suicide and finish everything before it starts at all. I feel disappointed for such patients and for myself—they are ignorant and they are harming themselves unintentionally and I can help them no more. It is dispiriting to spend your time and effort on a patient who will fail you most of the time. It renders your efforts pointless. Ignorance is a big problem here.
Doctors are a whole different story. Doctors are supposed to be the best of the best, yet some of them are troublemakers and make you regret dealing with them. Because of the dominant atmosphere of disrespect, doctors started to mask their real personalities or they create dual personalities. One personality is for patients and another one for everyone else. Of course the aggressive, harsh, and crude personality is for the patients because it is a self defence mechanism but sometimes it becomes so deep that a doctor forgets how to treat others gently even if they are his own colleagues. Unfortunately, sometimes they deal with you on a sectarian basis. It sometimes made me feel ashamed of being a doctor in such a setting because I am judged wrongly by non-medical personnel. One of the amusing stereotypes is that doctors with low ethics are most likely to become general surgeons—I served for three months in general surgery wards and it turned out to be true. Another stereotype is that the most polite doctors are in medical wards—also very true.
On the other hand, good things happen all the time. And we should all keep them in mind. The best thing that ever happened to me was that I helped others. You could say that every doctor is supposed to help others—so what’s new? The demands of health care in Iraq are qualitatively and quantitatively different. The quality of pain and injuries are different, so deep and so disabling are they for the patient. The numbers are so high that they are sometimes considered unbelievable.
Being left alone to handle major crises most of the time helps you gain many skills. The vast number of patients provides a good variety of cases and enriches your clinical experience, which I enjoy. I feel lucky to do things that an intern in the United States or the United Kingdom could never dream of doing even after five years of service in the medical field.
The privileges of being a hospital resident are also good in Iraq. You may ask yourself what’s good about living in a ward. The smell alone makes you feel sick. But the power is never off, the lights never turn down, the air cooler is always on, and tap water is always there. These are basic needs that are not met outside hospital and these are hard to live without. I feel doomed when I go back home where there is no air cooler and I cannot sleep because of the heat.
Finally, I am proud of everything I have done. I think I have done very well until now. I survived. I learnt too many things and lost nothing but time and labour. Sometimes it is good to start your life in a hard way so that when time passes things will become easier as you become more adaptable and more tolerant. One day I will be somewhere else and I will remember this time of struggle as a spark that made me turn bad things into good things. I have a lot of dreams that will never come true until I get out of here, out of Iraq, someday I hope.
Nabil Al Khalisi, intern Medical City Complex, Baghdad, Iraq
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