Let me say it right away: the best blog written by a doctor, at least that I've ever read, is by a provincial South African general surgeon who calls himself Bongi. He doesn't write about complex medical policy, and he doesn't worry too much about appropriate use criteria or whether a patient who needs anticoagulation should get warfarin or Xarelto. Instead, he writes about his astonishing experiences as a front-line surgeon (and, for many years, as a medical trainee) in a country on the border between first and third world medicine.
His stories will blow your head off. One minute you'll be laughing. The guy is seriously funny, possessing a keen sarcastic wit with an edgy South African accent. But then, suddenly, just when you're enjoying the antics of his colleagues and countrymen,he'll turn deadly serious, and leave you breathless or in tears.
Bongi is not just a surgeon. He is an artist, though I suspect he would hate that term. His posts are filled with misspellings and he doesn't believe in capital letters. Responding to a comment about this on his blog he explained:
i have a job that i do and do seriously. this is a hobby. if it becomes too much effort or too serious i might not enjoy it anymore.
But I don't entirely believe him. Since he started the blog in 2006 he's written hundreds of posts (though he's slowed down lately), and these constitute a serious, sustained effort to work out what it means to be a doctor, and a human being, in a deeply beautiful but entirely screwed-up and dangerous country. Reading the blog it is impossible not to be deeply touched by Bongi's deep love, but also deep cynicism, for his work and his country.
For anyone interested in medicine and surgery there is a load of fascinating information and detail. But, although Bongi loves-- literally and figuratively-- to dive right into the guts of a situation-- he also always insists on connecting these guts to the larger questions with which we all wrestle (or try to ignore). Bongi discovers that as a surgeon he has a unique and privileged perspective on these larger questions. Here is how he responds to some medical students who express a dislike for surgery, in part because it means dealing with certain, umm, unpleasant conditions:
...when you are unfortunate enough to get a perianal abscess, that part of your body that we all want to ignore becomes the center of your existence. the pain reminds you constantly of the presence of that specific section of your anatomy. you can no longer stop and smell the roses on the path of life because of the bloody pain in your rear. that which makes us human is put on hold and must move to a position of less importance to that part of the body that always occupies the position of least importance. if you see the perianal abscess in this light, to drain it is to return the patient's humanity to him. and if you see it as such, what a privilege i have to be the one to perform this task. the perianal abscess is a reason to study surgery, rather than a deterrent.
It's often hard to pin Bongi down for long. Brief as they are, his posts almost always offer several different ways of looking at complex topics, and he is content to raise questions and avoid delivering artificial resolutions. Consider this fascinating passage:
some time ago i went on a sort of tour around the lowveld to introduce myself to the doctors as a new surgeon. in one of the neighbouring little communities i met a gp. he told me a story that i actually believe. he said that a growing portion of his practice is made of hiv patients. some he keeps controlled on antiretrovirals. some present too late, basically in terminal aids. he usually tries to bustle them off to some or other hospital.... these people, in their desperate state often ask for a drip, possibly thinking it some sort of powerful western medicine. he complies, reasoning it may not do much but a vitamin boost isn't the worst thing for them. he then told me he struggles to charge them for this. sometimes he doesn't charge. sometimes he works it out that the equipment costs about r40. he puts a small profit margin on and charges about r60. (this is probably around $5). but then he said some of his patients complained because he wasn't giving them the good drip. when he asked what they were on about he was told that other doctors in the area... were charging r1000 for putting up a drip for these terminal hiv patients!
I really love this extended riff on the concept of "luck":
during that operation i thought quite a bit about old lucky [the patient's name]. the first thing i considered was the definition of luck from a surgical point of view. to start with, if you end up with a surgeon then you are not lucky. if a surgeon tells you you were lucky, you weren't. it is simply surgical jargon for we all thought you were going to die and you surprised us all by beating the odds. i mean he was pretty unlucky to have all those things happen to him but i can only account for him surviving so many different things, each of which would kill a mere mortal, at least in part due to luck. maybe lucky was very lucky. maybe he was unlucky. maybe he was both.
One persistent theme is the arrogance of surgeons. Bongi cheerfully admits-- and makes jokes about-- his own tendency in this direction:
when i was a registrar i used to tell my students that all surgeons believe they are the best surgeon there is. with only limited logic one can clearly see this is obviously a load of rubbish. how can every single surgeon be the best there is...when i am the best!! for some reason they always laughed.
But then he turns serious. He remembers a pediatric surgeon who gave him some advice while he (Bongi) was still a student:
a patient came in with a condition which was on the outer limits of his abilities... he felt totally out of his depths, but what could he do? there was no one else. he sucked it up and did what was needed. i found the story frightening and told him so. then he shared some hard wisdom. he was not the best surgeon there was for that child, but he was the only one available at the time. so for that patient at that moment, he was the best there was.
Years later he himself had a similar experience, as a general surgeon who normally doesn't work in the chest:
Recently i was required to open a chest in the state [public hospital] for a gunshot wound that just kept pumping bright red blood (the best type of blood to have inside the vasculature but the worst type to have outside). i phoned the thorax guy who informed me he was on leave and far away. he then helpfully suggested i refer the patient to pretoria. i mentioned that a ten minute trip for this guy was pushing it and there was no way he'd see the other end of a three-hour trip. then i did what i needed to do even though i am not overly comfortable on the inside of a chest. what choice was there?
i try to refer away whatever i feel is not in my scope but once the knife goes through the skin you become suddenly very alone. it is too late to think there is someone else who can do the job better than you. you must be the best for that patient at that moment. this becomes more acutely true when something goes wrong and you have to dig yourself out of a difficult situation. the thing about difficult situations in my line of work is if you handle them not too well someone may just end up dead. somehow to believe you are the best does seem to give just that little more of an edge.
Arrogance, in this case, is a necessary and useful quality. But he is brutally critical of surgeons and other doctors who are arrogant and cruel for no good reason. A substantial portion of his posts contain hilarious, and often bitter, portraits of many of his former teachers and supervisors, and the evil that results from their maniacal, out-of-control egos. Here's one example:
he tended to lose it sometimes and rip into one, sometimes for no clear reason. there was also usually no reprise. the entire firm [department] had been struggling under what was viewed as a fairly oppressive regime. the particular consultant was a typical surgeon. bombastic to the extreme. often cruel with the students (in my opinion anyway). but he also had the typical inflated surgeon's ego. he once openly claimed that he could keep up with the young bulls even though he was getting on in years. he meant on calls, which was a bit of a joke because he would typically get called out only about once every two months, whereas the 'young bulls' would typically work right through the night, through the next day and way into the next night on every call.
Sometimes Bongi himself succumbs to the temptations of cruelty and arrogance. The mind-numbing pressure of his job can cause compassion fatigue at times. Here he goes back and forth on the problem as he remembers the case of a car thief who lost his legs from gunshot wounds after being shot by the police:
as i lopped off the limb i reflected on this twenty something year old who now had to face the challenges of life without a leg to stand on. it seemed sad. but then i realised my own car had been stolen only about a month before and it was not completely impossible that this person could be the very person who had stolen my car. it was the life he had chosen and the risks were part of that life. i struggled to feel sorry for him. besides, i reflected, he would no longer be so fast when running away from cops in the future....
then one day i was required to go to some or other awkward social function. at that time my work was so all-encompassing i didn't get out much and it showed. i ended up standing away from the normal people and whenever i was forced to speak to one of them, when i looked at them my mind kept on repeating one phrase over and over again.
"fresh meat."
i needed a holiday.
One final note: although the blog is presented as true-to-life stories, there is of course no way to confirm the details. Responding to a comment, Bongi himself concedes that the stories may not all be absolutely true:
like pretty much all my posts, this one is a story based to a large extent on an incident that did happen. but it remains a story.
As in other great stories, the facts may not be entirely true. The larger truths remain.
A few suggested blog posts:
- An amazing case of petty bureaucratic obstruction during a genuine emergency.
- Breaking the news to a mother that her child did not survive an automobile accident.
- Surgical principle: break the tension, don't add to it.
- Thinking about karma and reverse karma. (Spoiler alert: he didn't let the kid drown, even though the reverse karma would have been awesome.)
- A harrowing story about the death of an 8-year-old girl with severe congenital heart disease.
- A story about bedside manner with an amazing twist.
- Another harrowing story about the indifference of nurses in a public hospital.
