Sunday, January 24

Making the Cut - Mohamed Khadra

Subtitled A Surgeon’s Stories of Life on the Edge, Making the Cut is the “impressionistic memoir” of an Australian surgeon, from the first time he incised a patient in theatre, through his own journey as a patient, to his decision to retire from clinical practice and teaching.
I generally enjoy reading about medical practitioners – though
Atul Gawande is far and away my favourite in the genre, he is not alone. I rarely buy books now, but Making the Cut was on my wanted list for a long time, and when last year I decided to cheer myself up before having hand surgery, I bought a small stack of new works, including Khadra’s

collection of impressions and retellings that are meant to raise issues about health, surgery, death and dying…[featuring] amalgams of characters and events and fictionalised places and names…I have tried to imagine for the characters a persona and a life outside my contact with them so as to accentuate their humanity to the reader… based… on conversations and snippets of insight I gleaned from my interactions with the doctors who cared for these patients, or with my conversations with these patients themselves.
Believing doctors should be well rounded and educated, Khadra insisted that his students open their tutorial sessions with a poem, and each chapter of Making the Cut does so too.
At times Khadra well encapsulates the frustrating aspects of medicine – the utter exhaustion of long hours and high pressure, unnecessary and futile attempts at resuscitation, intervening in the deterioration of a respected colleague, the tension in private practice between generating revenue and exposing patients to as little risk (ie surgery) as possible, the ease with which mistakes can be made, and the awful consequences of these mistakes.
But he has several points he’s at pains to make. Chief among these is his dissatisfaction with the Australian health care system, from the change in equipment purchasing from surgeons deciding what they need themselves to large expense panels, to the kinds of meals served in public hospitals and refurbishment (or lack thereof) of patient facilities. As a cardiac inpatient Khadra pities the lay patients who “were not armed with the knowledge to influence their passage through the health system… the number to call maintenance to grease the squeaky door… the supervisor to call to ensure [their] bathroom was kept clean.” Reading these sections without having any knowledge of the Australian public health care sector would paint a very dark picture, and one that is almost wholly incongruent with my experience.
He also has very definite ideas about nurses – though he acknowledges that a good (“experienced and sensible”) nurse can make life easy, Khadra has no time for the new breed of university educated nurses, “custodian[s] of quality, the barometer of good care… bureaucrats rather than carers.” In Khadra’s view, if “you are a good clinical nurse then you get promoted to administration, the worst-paid job is to look after the patients” – by default, floor nurses must not be good clinicians. I don’t disagree with all his positions, and certainly agree that by qualification hospital trained nurses “had seen a lot of illness and health and certainly knew what a nurse does for a living” while university educated graduates come out with different knowledge. But I think his perception that newer nurses’ focus on charts and tools and instruments of measurement comes from a lack of awareness of patient care is misplaced – it comes from administration requirements that, though they take away from time on the floor, apparently improve patient outcomes and for which nurses are responsible in addition to all their other jobs. And while some students may think they’re above bed making, few and far between are newly graduated nurses who are allowed to believe that.
Women in general do not come out well, particularly the greedy, grasping wife of one surgeon, whose focus on money and things inextricably leads to his premature death. It’s in vignettes like this that I was particularly uncomfortable with the knowledge that many of these cases are both hearsay (or ‘retelling”) and embroidered with fictionalised additions. There are few female surgeons (and no male nurses), and though the most sympathetic treatment received is to a pre-op male-to-female transsexual, Jo is referred to throughout as “he.”
Khadred discusses the stresses on doctors, referring to the hospital as a “hell zone” that family moments (like a child opening a present or a wife showing off a new nightgown) bring back in full force (the parent who’ll never see their child’s joy again, the patient who died in a similar nightgown). I agree that there’s a lot of pressure on doctors, that their suicide rate is unreasonably high and unaddressed, as is their rate of alcohol and drug abuse, and that a great deal of this pressure is internal. And, in what I suspect is an inadvertent reflection of this within the profession, Khadred recounts two suicides by doctors and references at least two more, with little sympathy or surrounding detail. He also

to this day look[s] down on doctors who take time off. For me, the worst offenders are those that take stress leave, whatever that may be. I have always lived by the aphorism ‘stress is good for you, it flushes the coronary arteries.’
Not a lot of scope for support there.
Although he acknowledges we should consider quality of life over (or perhaps instead of) longevity, Khadred reports that he stopped exercising when he read that, for each hour spent exercising in youth, an hour is added at the end "when there is a good chance every day would be a prayer for death." This view of cardiovascular health is certainly unusual in a health professional, not to mention what it says of his perception of the aged and aged care.
This is not to say that I disagree with all of Khadra’s opinions. I agree that we make poor decisions about end-of-life care, though I think the statistic that “about 70% of the health budget is spent on caring for patients in their last six months of life,” though accurate, is misleading – the picture most people have, of old people being medicalised to the last breath, is not always the case; some of that 70% goes on patients whose first six months is also their last, on patients battling potentially survivable cancers, on previously well patients who present in terminal distress of one kind or other, and on trauma patients.
I found Khadra unsympathetic, and Making the Cut disappointing and depressing. As mentioned, I disagree with his portrayal of the Australian health system, though I acknowledge that my experience of it has been primarily with one institution and rarely as a patient. I also found his tone irritating, and didn't really understand what the point of Making the Cut was or at which audience the book was aimed. In parts a plea for economic rationalism in health care, in others an uninspiring autobiography, and at times an insider's portrayal of modern medical practice, it somehow failed to be even as much as a sum of its parts. I think a return to Gawande is in order - Alex

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