As a young medical student from Soweto, Maria Phalime had high expectations for life as a doctor. Then she started to practise and was confronted with inhuman hours, overflowing emergency rooms and poor resources. Her book Postmortem: The Doctor Who Walked Away exposes the pressures that come with being a doctor in South Africa. This is a condensed, edited extract:
On a number of occasions members of the nursing staff at Site B would come to me requesting I write them a prescription. The story usually went something like this: My child is asthmatic. She attends the asthma clinic at Red Cross Hospital. She's well at the moment but we've run out of her chronic medication.
I don’t want to let her miss school just to go to the hospital; would you mind writing a prescription?
I would oblige. They would pass me a piece of paper on which the child's medication was written and, after making sure that the child was in no need of medical attention, I would write up the requested script.
I trusted them; after all, we were colleagues.
One morning one of the other doctors walked into my room as I was handing the prescription to a nurse. He watched the exchange in silence, and then spoke as soon as the nurse had left.
"So you're in on it, are you?" he said.
I frowned. "In on what?"
"You mean you don't know?"
He shook his head briefly before proceeding to fill me in on the scam. There was no sick child, or at least not in the way the story was sold to me. The nurses would take the prescriptions to a pharmacist who would in turn submit claims to their medical aid schemes, without dispensing the medication.
Instead, the nurses would be allowed to take toiletries of an agreed value from the pharmacy while the pharmacist pocketed the medical aid disbursements. It was a win-win arrangement for nurse and pharmacist.
I was livid when I realised that my desire to help had inadvertently drawn me into a criminal triangle. And for a basket of toiletries! What hope was there for poor destitute people when so-called professionals behaved in this way?
Patients need a reason to get up in the morningI was nearing the end of my community service and I was no closer to figuring out what I wanted to do with my career. I didn't want to be around patients and their problems. I felt I couldn't help them. The medication that I was dishing out was doing little to change their lives. What many of those patients needed was a reason to get up in the morning: jobs, prospects, to be able to feed and clothe their children.
But how could I be thinking about leaving the medical profession when there was still so much about it that I loved? For one, it offered an unprecedented opportunity to touch the lives of other people.
Patients came to me at their most vulnerable, and they entrusted me with their troubles and their lives. My privileged position as a doctor allowed me an intimate view into the drama of people's lives.
Though often tragic, I also got to witness courage and the strength of the human spirit.
Now I was thinking of leaving. How could I want to give up on a dream? What would others think? What would I do if I left?
These questions swam around in my mind for months, often clouding my thinking.
But every so often I would have moments when, with sobering clarity, I knew what I needed to do.
One Saturday nightOne Saturday night I was on call at a clinic in Site B in Khayelitsha. On my drive to the clinic I had passed groups of youngsters – some just loitering around; others talking and laughing as they walked, presumably to a favoured drinking spot, where they would while away the night.
I'd eye them grudgingly, knowing that some of them would end up in our emergency room at some point during the course of the evening.
That night was no different to any other that I'd worked there.
Throughout the night, patients filled the benches outside the two cubicles where the doctors sat, shuffling along as they awaited their turn. They were all injured, most not seriously – women who had been beaten by their boyfriends; friends who had fought and then stabbed each other; minor gunshot wounds.
Serious injuriesSome of the injuries were serious. Two men were brought in by another, a stranger who had been speeding his car and had run them over as they stumbled in the street, drunk.
He had killed one of them and seriously injured the other. The driver himself had been drinking but I imagine sobriety must have set in quickly when he realised he was probably facing many years in prison.
I worked with another doctor during the night and together we saw scores of patients. By morning the ones we left in the emergency room were waiting for ambulances to take them to Jooste and Groote Schuur hospitals.
I heard the commotion as I was preparing my handover notes for the doctors who would be taking over the day shift.
"I’ve been left here to die," the man shouted. "What kind of place is this? Why has nobody attended to me?"
"No, bhuti [brother], the doctor has already seen you," the nurse responded, but she was quickly shouted down. "Nobody has seen me!" he bellowed again.
I got up to investigate.
I recognised the patient; I had seen him when he'd arrived at around four o’clock in the morning. He'd been stabbed in the back, the knife making a deep gash in the fleshy muscle just under his right shoulder blade.
Transfer to hospitalHe had bled profusely from his injury and when he’d come in the priority had been to stem the bleeding and to rehydrate him. His wound was too deep to be stitched up at the clinic; he was due to be transferred to Jooste for assessment by the surgeons.
He was extremely drunk when he came in, which was probably why he didn't remember being seen by a doctor.
I intervened. "Bhuti, I attended you when you came in earlier," I began, but he wasn’t listening. "I’ve been left to die," he spat.
I took his folder from the end of the bed and opened it to my notes. "Look here, bhuti, this is my writing. You are waiting for an ambulance to come and fetch you," I said, pointing at the date and time to try to drive the point home.
He was having none of it.
He flicked the folder from my hand and clicked his tongue to dismiss me. I turned to the nurse and we exchanged exasperated looks, then I walked away to finish off my notes.
I'd forgotten about that man by the time I drove out the clinic gates. The day staff had taken over and I was going home to shower and sleep.
Standing on the pavementAnd then I saw him. He was standing on the pavement outside the clinic, trying to wave down a taxi. He was topless, and the pressure dressing we'd applied over his wound was heavily soaked with blood.
I stopped the car; my instinct was to run to him and persuade him to go back to the clinic. His wound needed attention.
But I stayed in the car, watching from a distance. He was waving his arms frantically at the taxis passing by, the aggression I'd witnessed earlier plainly evident in his gestures. I watched in silence as a taxi finally stopped and he got in.
When it drove off I engaged my gears and resumed my journey home.
For some time I had been asking for answers about the direction that my professional career needed to take, and right there was a sign. After all, what kind of doctor drives away from a patient in need?
Maria Phalime is a medical doctor and the recipient of the City Press Tafelberg nonfiction award for 2013
Have something to say? Tweet or Facebook us on @Bhekisisa_MG
Exhausted doctors endanger health
SA needs rural doctors
M&G Newsroom: Bara doctors protest, prisoners' rights spotlighted
The project’s closure six months ago forced some injecting drug users to share needles and risk infections such as HIV and Hepatitis C.
Men can help to prevent new HIV infections by showing up for their partners. Here’s how:
Until two years ago, it was Sibonelo Gumede’s job to help developers get rid of people who used drugs in neighbourhoods. Then his life changed.
Bhekisisa means "to scrutinise" in Zulu
In South Africa, Zulu patients who would like to be thoroughly assessed by a doctor, would ask the physician to "bhekisisa" them.