politics

being a registrar involves managing people:

- its leading and teaching the residents, interns and medical students.

- its liaising with all of the consultants, working around their varied styles.

- its coordinating care with the other medical teams, nurses, allied health, hospital administration - knowing when to compromise and when to stand firm.

- its also about looking after myself - recognising when im tired, hungry or close to losing my temper, then stepping back from the brink.

all of these tasks are crucial to being a good registrar. but, for me, i would still like to believe they're secondary to caring for my patients and their families. now may be ive got that wrong. but im yet to find out the hard way.

my patient is dying. she has a prognosis of days. all of her energy and will is directed towards a significant family event that has been looming for months. afterwards, i would not be surprised if she fades quickly to nothing. i have seen it before. many times.

she has not been the easiest patient to look after. at times, she refuses our recommendations. she has her own reasons for these choices, and although i do not agree with them, they are not random or irrational, so i respect them. patient autonomy is a cornerstone of medical ethics that i believe in and guides my medical practice.

however, another key tenet of medical ethics is that of resource allocation. the hospital is full. patients are backed up out the doors of the emergency department. there is a bed at the palliative care unit, where my patients care needs would be better met. but she has consistently refused to go back there after a previous bad experience, despite our attempts to overcome this. she is taking up an acute bed and other patients' care are being compromised as a result of this. (of course, the other patients' care also also being compromised as as result of bad planning by the hospital administrators - but naturally this is not something they would consider.) the hospital administrators tell me that i must send her to the palliative care unit, against her wishes, or discharge her home, where her care needs could not possibly be met.

naturally, i refuse. patient autonomy trumps resource allocation. so the drama escalates. i am called away from patient care by various urgent pages, phone calls and meetings. my suggestions for alternatives are ignored. more patient care is compromised but the hospital administrators do not see this. they want her out. everything else must wait.

i give in and try again. i shake her awake from her restless sleep. she is drowsy and drifts in and out of the conversation. i make promises i don't know if i can keep. she seems to understand, and finally nods yes.

i leave feeling like ive done a bad thing.