The Medicine

A Doctor's Notes

Karen Hitchcock

• Publisher: Black Inc.
• Year: 2020
• ISBN:
  9781743821275
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

What happens when a doctor kills a patient? Are GPs overprescribing antidepressants? Does 'female Viagra' work? What role can psychedelics and cannabis play in treating pain? What is sickness, and how much of it is in our heads?In The Medicine, Dr Karen Hitchcock takes us to the frontlines of everyday treatment, turning her acute gaze to everything from the flu season to dementia, plastic surgery to the humble sick day. In an overcrowded, underfunded medical system, she explores how more of us can be healthier, and how listening carefully to a patient's experience can be as important as prescribing a pill. These dazzling essays show Hitchcock to be one of the most fearless and illuminating medical thinkers of our time – reasonable, insightful and deeply humane.

OTHER APPETITES

Precious Sleep

Legend has it that Margaret Thatcher needed only four hours’ sleep each night. It’s probably not true that that’s all she needed, though like some kind of sleep anorexic it may have been all she allowed herself. Mean appetites don’t tend to arise “naturally”. We’re greedy little animals when it comes to our so-called vegetative functions (sleeping, eating, drinking, sex). Sleep deprivation may even have accounted for Thatcher’s (equally legendary) hair-trigger tempers and baseline vile mood. Spending your whole life dog-tired, hungry, thirsty or sexually frustrated effectively turns anyone into an arsehole.

Last night, I slept for ten hours. For the first time in months I woke gradually to a clear, benevolent world. My vision was sharp, the air soft. It’s pretty rare for a working urbanite to sleep long and sound, and wake full term. And it’s unusual for us to allow something that feels this good to occur so rarely. You’d think we would have worked out some efficient and cheap way of fulfilling our requirements. After all, we can deal with the other basic bodily functions in this way: fast food, water bottles, porn. Why can’t we deliver a big fat sleep in a way that takes up less of our time?

Sleep can be a slippery little sucker, even when you have the time and the appetite for it. Doctors advise insomniacs to attend to their “sleep hygiene”, as if beds are some kind of viraemic cesspool that might be cleaned up with a splash of bleach. Michael Jackson bought and controlled his sleep with a nightly physician-delivered anaesthetic. It was the kind they give you before a colonoscopy and ask you to count to ten. Any substance that offers an extended period of knockout brings with it a decent chance of death. And most of the drugs that can give us a few hours of sleep on demand are extremely addictive. We haven’t figured out a safe way of buying and selling high-quality sleep, of getting it whenever and wherever we want – or how to get, in a packet, whatever it is that sleep gives us.

I was an insomniac child. Terrified to go to sleep, and then awake through the early hours. I don’t remember fatigue. Just the terrible wait for morning, intermittently peering behind the blind, hoping the orange crack was no longer from the sodium lamp, but from the sun. If I’d been taken to a doctor I may have been given a handful of diagnoses. Difficulty falling asleep: anxiety. Early-morning wakening: depression.

Patients rarely report sleeping abundantly and well. They nap on the couch, at their desk, some more at the wheel. Or they’ve got it down to six hours and five coffees, supplemented with long catch-ups on the weekend. Or their soft bed, no matter how early they take to it, becomes a lumpen torture chamber lined with strangling damp sheets. Who hasn’t fallen exhausted into bed, hoping for respite, a little annihilation, only to find – the moment head and pillow collide – that their heart has been ousted by a crazed bat?

Sleep demands that we relinquish vigilance and embrace solitude. We dream thoughts we didn’t even know we had, in full-colour, 3D playgrounds. We must close our eyes and surrender, as if to death.

I once heard a colleague being interviewed on the radio about the ubiquity of chronic sleep deprivation. He asked the interviewer if she woke to her alarm. Yes, of course she did. “Well,” he primly said, “that means you don’t go to bed early enough.” The announcer gave a no-shit-Sherlock pause and then reeled off her excuses, ones we all know and would ourselves offer. We trade sleep for life. For non-work life. We trade it to talk and watch and eat and drink and relax and play. I’d happily pay with a day of feeling wobbly to watch a couple more episodes of UnREAL.

When I first heard about the Iron Lady’s four-hour regimen, I was jealous. All those extra hours of consciousness. I did the sums: she’d earned herself thirteen bonus years. Maybe that additional stretch would be worth the lifetime spent feeling like crap? But sleep deprivation is not good for you. Apart from all the diseases it causes or accelerates, it also leads to impaired decision-making, a decline in empathy, a shrinking of perspective. A kind of recipe for neoliberalism.

Time – to paraphrase Seneca – is the most precious thing we have and the thing we most thoughtlessly squander. Thatcher and her four hours functioned as a paragon to which all good citizens should aspire. Why waste time sleeping like a weakling when you could be awake producing and profiting? And when that’s the goal, enough’s never enough. Should some mad scientist work out a way to keep us all going without sleep, we’d just polyfill the extra time and then want more.

We can rush and cram, lull and white-noise through our days. But, come night, we must climb into bed and close our eyes, if only to be reminded that our hours are limited, our life finite, our time priceless and relentlessly shrinking. Perhaps the epidemic of disordered sleep is actually a disorder of the way we are – or are not – living.

A Former Smoker’s Lament

I started smoking in high school and happily dedicated myself to the practice for ten years. Ex-smokers adore reminiscing – our favourite brands, when we started and stopped, the best cigarette of the day, what it was like to exhale a magnificent plume on a freezing cold morning. We’re like nostalgic diggers who discover we all knew the same guy, a most loyal and lovable soldier, and are desperate to share our tales. Friends who were never smokers listen with what-the-fucks plastered all over their faces.

In June 2015, there was a riot in a men’s prison in Melbourne, apparently in response to a statewide smoking ban due to take effect the following day. The prison sits on a body of barren government land, Ravenhall, a few hundred metres from where I grew up. When I was a kid, my dad was mates with a sheep farmer who rented Ravenhall for his flock. Dad kept an eye on the property during the weekends, pulling out lambs stuck mid-birth, shooting hundreds of rabbits for dinners. My grandmother owned the land next door, until the government hit her with an involuntary-acquisition order, razed her almond orchard and built a women’s prison next to the men’s one. I imagine them all, locked behind concrete, being “rehabilitated”, on the paddocks of my youth. And now they can’t even smoke.

There was an enormous drainpipe near my childhood street that stretched for 2 kilometres under houses and roads and paddocks until it stopped at a little chimney you could climb up into and peer out straight into Ravenhall. My friends and I would skip school and make the trek through the pipe, a voluntary, illicit entrapment that felt like freedom. We always made sure we had cigarettes in our pockets, but we never actually smoked them in the pitch-black of the drainpipe. It’s a funny thing about smoking I’ve often discussed with my ex-smoker friends: there’s little pleasure if you can’t see the smoke coming out of your mouth. That smooth stream of white – a willed act of creation, like art.

I recently took a friend to see the pipe. We found the opening barred with a heavy iron grate. Maybe to keep the kids out. Or – thinking of drug lord El Chapo’s tunnel escape from a Mexican jail – maybe to keep the prisoners in.

In 2010 I read Susannah Hunnewell’s interview with Michel Houellebecq. Hunnewell noted that throughout the two days she spent with the French author, he continually smoked something she called an electronic cigarette. “It glowed red when he inhaled, producing steam instead of smoke.” I’d never heard of electronic cigarettes and I hadn’t had a cigarette for sixteen years, but my pulse quickened. I researched online. The steam was repeatedly described as “harmless water vapour”. Imagine, I thought, being able to once again form those great white plumes, without getting emphysema. It was years before every hipster at a tram stop would be holding elaborate vaping devices, blowing steam like bearded dragons. They weren’t yet available in Australia, so I ordered a few kits from the US. I chose the elegant, pencil-thin black devices and imagined myself swanning to breakfast at Tiffany’s. Unfortunately, the taste was oily and repugnant, and it seemed to me that the stuff going in and out of my lungs contained a lot more than water.

By 2013 all the large cigarette companies were marketing and selling e-cigarettes. And they’re using the same old tricks they’ve used for decades to promote combustible tobacco: funding consumer-rights groups, fudging health claims, lobbying regulatory agencies, deploying celebrity drones. Studies to date show that while these devices are likely less harmful than real cigarettes, they do contain multiple toxins, usually don’t lead to smoking cessation, and probably initiate young people into smoking the real thing. Yet another corporate promise of safe, easy pleasure shattered.

As a child, cigarettes were an integral part of my nascent identity. They were potent symbols of freedom, a small act of rebellion against what were hundreds of adult-generated interdicts. Adolescence: one long riot. Now, I read about Big Tobacco and hear them declare their “commitment to harm reduction” and find it troubling that I might be writing a kind of love song to their evil goods. How much of the rebellious freedom I felt while I smoked was the result of their insidious marketing? Was it simply a case of addiction?

The word “addiction” has always made me twitchy. It seems like one of those words specifically designed to arrest thinking. A word you can wield like a lasso, simplifying and reducing any individual to whom it is applied into a silent, captive beast: “I accidentally smoked ice and now my brain cells are forcing me to continue.” The websites of addiction specialists argue that any non-neurobiological explanation is moralistic. It’s all in the brain, it’s all about reward centres and dopamine feedback loops.

Countless international professorial hours over decades have been spent debating exactly what term to use to describe and thus diagnose someone’s problematic use of a substance. “Addiction” was dumped for “dependence”, and now the preferred terminology is “substance use disorder”. According to the most recent Diagnostic and Statistical Manual of Mental Disorders (psychiatry’s bible), if the use or desire for a substance leads to clinically significant distress or impairment, you’ve got a disorder.

My beloved period of smoking caused me no distress beyond the occasional school detention and has left me with no significant impairments. So I suppose I escape a psychiatric diagnosis. I quit – and stay quit – because I really don’t want to die. But if I wasn’t lucky enough to desperately want to live – and if I hadn’t forged better ways to assert my freedom – I know I’d still smoke my guts out. And were I in prison, I too would riot.

A Fine Line

I once worked with a doctor who spent six months preparing for her high-school reunion. She went on a diet, joined a gym, had her boobs done, got her face resurfaced, filled and botoxed. She experimented with eyelash and hair extensions. She’d detail her endeavours to anyone who’d even half listen and wrap it up the same way every time: “I’m gonna show those bitches.” She was deaf to exhortations, blind to our looks of horror and discomfort. She’d entered some kind of mad alternative universe. Her party came and went and she was satisfied she’d shown them, those ageing horrors. She said she needn’t have bothered trying. I know, right? No one told her that that’s what everyone thinks.

Full-blown neurosis and benign protective delusions aside, it’s arguably getting tougher for the average woman to embrace her deepening wrinkles and slackening skin. We watch celebrity faces stay smooth as photoshopped cream, rich with the possibility that we too might escape the spoil. Aesthetic procedures are on the rise. In women’s magazines, plastic surgery has become the new cold cream. They say you should start young. Take Madonna: a ton of work, a bit of make-up and a pair of gloves have kept her sort of thirty-five for more than two decades.

I used to think plastic surgery was all boob and nose jobs, face lifts and tummy tucks. But in the public hospital, plastic surgeons treat burn victims, skin cancer sufferers and people with disfiguring, function-impairing injuries. They reconstruct, reattach and graft.

In medical-school interviews, prospective students are asked to explain why they want to become doctors. A friend of mine who grew up in rural New South Wales intended to return to his hometown and work as a general surgeon. Tough gig. Mending all those stoic late presenters and farm accident victims, working horrific hours, being constantly on call with little back-up. Declaring this ambition in his interview probably gained him instant admission to the course.

Midway through his training he fell in love with a beautiful GP, who wore icepick heels and emerald-green silk dresses to work. “As soon as I clapped eyes on her,” my friend said, his hand kneading his forehead as if divided loyalties could be massaged away, “I knew I’d be staying in the city.”

My friend married the GP, dropped out of surgical training and became a “cosmetic physician”, performing all the minimally invasive procedures: office-chair injectables and laser treatments, day-case fat removal and silicone implantation. This causes him terrible periodic guilt. He could have completed real plastics training and done stints in developing countries fixing cleft palates. I like him and always feel an urge to defend him against himself. It’s not like he’s performing labiaplasty on porn-normed young women. He’s just the product of our medical system and society: consumer-centred, fee-for-service and privatised.

Psychology and surgical journals are full of studies trying to measure the success of aesthetic procedures, with titles such as “Objective Assessment of Perceived Age Reversal and Improvement in Attractiveness After Aging Face Surgery” and “The Effect of Incobotulinumtoxin A and Dermal Filler Treatment on Perception of Age, Health, and Attractiveness of Female Faces”. They tie themselves in knots trying to work out what they are measuring and how. Unknowingly, they’re attempting to reduce complex philosophical matters to empirical equations – beauty on a scale of one to ten – believing that human perception can be rendered objective. Researchers have groups of “raters” estimate the age or the level of attractiveness of people from pre- and post-surgery photographs. One study determined that a face lift “objectively” saves 3.1 years on average, but doesn’t improve scores of attractiveness. Another study found the average number of years saved to be 4.6.

My grandmother would have been an enthusiastic rater. When I was a teenager she’d tell me, at least once a week, “Remember, you never see yourself as others see you.” She usually said it in an attempt to get me to use less eyeliner or remove my leopard-skin coat. I thought it was her only dodgy aphorism: the last of the Victorians versus Gen X. It turns out she was right. But wrong about what should follow.

What all the plastics research proves is that how you think you look has very little to do with what those others might think. Despite woefully modest improvements in how a group of strangers reckon you scrub up, studies pretty consistently show that when people have their face nipped and tucked, paralysed and filled, they experience major decreases in physical, emotional and social distress.

My friend feels guilty for saving skin-years rather than lives, for helping to promote a ludicrous and no doubt sexist aesthetic regime. But the aesthetic surgeons and cosmetic physicians are ultimately operating on their patients’ (or customers’) internal portraits, on their fantasies, on self-perception. The operations work in much the same way as placebos or luxury brands do. Big fantasies hinge on tiny things: sugar pills, waitlist handbags, heavy watches, three fewer wrinkles. And buyer beware: Michael Jackson’s slowly butchered face probably made him feel better and better.

Recently I was onstage with author Renata Singer and stand-up comedian Mandy Nolan. We were discussing societal attitudes to ageing and how unfortunate it is that we eschew its visible manifestations. Singer turned to Nolan and said, “Well, what about make-up? Where’s the line, Mandy?” Nolan raised her eyebrows. “Where’s the line? I know where the line is.” She struck her finger to her forehead. “The fucken line’s here.” A shallow crease on the forehead, a ravine in the mind.

Sex and Pharmaceuticals

Towards the end of 2015, in a third-time-lucky bid by Sprout Pharmaceuticals, the US Food and Drug Administration (FDA) gave its tick of approval to a new drug called flibanserin. It was the first drug approved to treat “female sexual interest/arousal disorder”. The following day, Valeant, a major pharmaceutical company, acquired Sprout for $1 billion. Flibanserin – colloquially known as “the female Viagra” and marketed under the trade name Addyi – had been twice rejected by the FDA, due to its dangerous side effects and minimal efficacy. The drug was a failed antidepressant shown in trials to increase the number of “sexually satisfying events” by about half an “event” per month, when taken daily. Fainting and sedation are common, and complete abstinence from alcohol is necessary while on the medication. Upon the drug’s FDA approval, Dr Irwin Goldstein, a sexual-medicine expert and paid consultant for Sprout, said, “If you have a broken leg, a broken toe, or a broken libido, you can now go to a doctor and get help.”

Studies show that about 40 per cent of women report some sort of sexual problem, and that about half those women are distressed about it. The numbers aren’t dissimilar for males. When a man goes to a doctor with a troubling sexual problem, it’s usually because he can’t get or maintain an erection, or because he prematurely ejaculates (officially defined as “less than one minute of penetration”). The most common distressing symptoms reported by female patients are painful sex or a lack of interest or pleasure in sex. Male patient...

Table of contents

• Cover Page
• Also by Karen Hitchcock
• Title Page
• Copyright
• Dedication
• Contents
• Introduction
• Doctor At Home
• Aged Care
• Pills, Pills, Pills
• Food and Health
• Other Appetites
• The Body and The Mind
• Doctor on The Ward
• Ethics
• The System
• Acknowledgements
• About the Author
• Back Cover