VOLUME 11    NUMBER 2    2024    19-24     NOT WITH A BANG, BUT WITH LOVE  AND GRATITUDE     Hilton Koppe  Lennox Head, NSW, Australia  hiltonkoppe@gmail.com     KEYWORDS: Physician burnout, Post Traumatic Stress Disorder, Vulnerability, Reflective writing, Healing  IN THE 1990S   I  was a thirty-year-old freshly minted family doctor working in a rural village of 800 people. I  d left my family and friends and colleagues in Sydney for the wide horizons of a life as a country doc. It was a spur of the moment decision. I  d stopped for a toilet break on a road trip. Got chatting with the woman in the ice  cream shop. She told me that she had moved from the city and how much she enjoyed her new life.   Sounds great. You don  t happen to know of a job for a doctor in town, do you?   I quipped.   Well, as a matter of fact, one of our doctors was killed in a car accident last week,   was her response which changed the direction of my life. Within a couple of months, I was the new doctor in town. I was different to my predecessor. I was younger. Less experienced. Male. The people I now cared for tried to help me adjust to my new environment.   Dr Carol didn  t do it that way!   So, I learnt to pretend. I worked very hard at trying to be a good doctor. It was exhausting. Sometimes the veneer of bravado was sufficient. Thankfully I didn  t have to pretend when I saw the children of the village. They were happy to accept me as I was. They didn  t mind that I wasn  t Dr Carol. They only cared that I cared. Once their parents could see that their children were happy to come to see me, they relaxed a bit too. Word must have spread around town that the new doctor was okay.   My friend (or daughter or wife) said I should make an appointment to see you.    © 2024 Hilton Koppe. This article is distributed under the terms of the Creative Commons License CC BY.    International Journal of Whole Person Care  Vol 11, No 2 (2024)      Not with a bang, but with love and gratitude Hilton Koppe   I found myself being a bit more relaxed at work as I felt able to be myself rather than my idea of what a doctor should be. But offering cradle to grave medical care meant there were moments of uncertainty.   I wonder what a real doctor would do in this situation?   Caring for Judy offered me an opportunity to learn from uncertainty. Judy and her husband Geoff were university academics. They were pre-internet tree-changers, having moved 800km from their sandstone institutions to live the good life. This risky move was prompted by Judy  s diagnosis in her early forties of a rare slowly progressive kidney disease. There were no kidney doctors in our area. Judy arranged appointments with her specialist in the city to coincide with her visits back to the university. Kidney medicine was my weakest area. Too many interactions between weird chemicals and complex pathways for my simple linear mind. Pretence was impossible for me. Fortunately, Judy and Geoff had become experts. Their research skills were put to good use. When we found ourselves at a new juncture in Judy  s journey, I  d often end up asking them   I  m not sure what we should do next. What do you think?   Or   I don  t know what  s going on here, would you like me to phone your specialist?   We successfully negotiated this dance for years. Until the lightning bolt hit me. My room at the clinic faced west. I was finishing up work one evening and was struck simultaneously by the beauty of the sunset outside the window and by a deeply disturbing thought.   As much as I love my work and I love my life here, I don  t want to still be sitting in this room watching the sun set in 10 or 20 or 30 years   time.   A movie of this potential version of my life flashed through my mind. Followed by an urgent call to action,   I  ve gotta get out of here before it  s too late.   This urgent call to action surprised me. It was out of step with my normal considered approach to big decisions. But it wouldn  t leave me alone. Even though I couldn  t understand why I felt so strongly that I needed to get away, something inside me was speaking more forcefully than the more timid voice saying   You  re risking everything for a whim? Why would you even consider doing such a thing?   My wife and I bought a small 4x4 SUV and a camper trailer. We were going to do   The Lap  ! The excitement of planning for our year traveling around Australia was tempered by having to say goodbye to my patients, people I  d got to know so well over the previous seven years. I wondered how something could feel so right and so wrong at the same time. Judy and Geoff were in Sydney during this time of goodbyes. The super-efficient small-town grapevine got the news to them that I was leaving. A card arrived in the mail the day before we headed off.  International Journal of Whole Person Care  Vol 11 No 2 (2024)     20     Not with a bang, but with love and gratitude Hilton Koppe   Dear Hilton, We both wanted to thank you for your care during our time together. We appreciated many things you did for us. But mostly we were grateful for your ability to say   I don  t know   when you weren  t sure what to do next. We  ve seen too many doctors over the years, and you have been the only one to be that honest with us. Thank you, thank you, thank you. We will miss you but are so happy that you are following your dream. Judy and Geoff  IN THE 2000S  I was a freshly minted father in my early forties. Fatherhood tapped into a previously hidden well of love. The power of this love for my son and daughter spilled over into a love for all children. There were times when this love intruded into my rational doctor  s mind. I found myself overly worrying about the children I cared for. There is a saying in medical circles.   If a doctor treats their own family members, then their family will be either hopelessly overtreated or hopelessly undertreated.   I hoped that my newfound love for all children was not clouding my medical judgement is a similar way. After our daughter was born, I found myself again a new doctor in a new town. Like my grandparents and parents, we had moved towns to give our kids a better life. My inner battles to be accepted as the new doctor were not as vigorous this time. As a mid-career doctor, I had found an acceptable balance between professionalism and humanism. Or so I thought. Until I met Sandra. Sandra had just returned to our small town after six months in the city with her daughter Tahlia who was being treated for leukaemia. Tahlia was four years old. The same age as our daughter. When I first met Sandra, she told me how difficult her time had been in the city. All the fears she held for Tahlia. The effort in trying to balance keeping her safe while trusting the invasive and toxic treatment necessary to offer a cure. She lamented how little attention was paid to her personal needs as a mother of a critically ill child. I suspected that she felt it was okay to ask for help for herself, now that the initial treatment phase for Tahlia was over. As I was offering Sandra my complete support      I want this room to be a kind of sanctuary for you. A place where you can let your guard down. If you ever need to.      I was struck by an unexpected and most disturbing vision. I saw my daughter in Tahlia  s position    fighting for her life.   Not my little girl,   my mind silently screamed as I envisioned our daughter bald, bloated from steroids, barely recognisable, as I had seen many young children during treatment for leukaemia.  International Journal of Whole Person Care  Vol 11 No 2 (2024)     21     Not with a bang, but with love and gratitude Hilton Koppe   And I was no longer with Sandra. I was grieving for an imagined horror facing our daughter. I started to cry. To cry. In the middle of a conversation with a traumatised woman whom I had just offered safety and sanctuary. How could I let this happen? Somehow, I managed to pull myself back together and we completed the visit. I imagined that I would never see Sandra again. That she would want to see a real doctor. The following week, a card was waiting for me at the reception desk. It was from Sandra. Dear Dr Hilton, I have been thinking a lot about what happened when we met last week, and have been wondering if perhaps you might have been feeling shame or guilt about shedding some tears during our conversation. I guess there is something really complex about the cultural expectations of men and the roles of doctors in our society.... "A doctor should hold it together in front of their patients. Men shouldn't cry, they should be the strong ones otherwise they are weak". So being a male doc, you have a double whammy. You saw me at my most vulnerable last week. You had courage in abundance when you showed me your vulnerability via your tears. You responded to my pain in a way that allowed me to instantly connect with you and really know I was safe in that room to tell you or say whatever I had to no matter how dark or sad it was. You brought to fruition the message that vulnerability is a strength (not a weakness as most of us have learned to believe) because if you had shut me off with the usual clinical distance that is very common in medical settings, I may not have connected with you. Little did you know, I was going out on a limb that day, reaching out to say,   I have just had 6 months of clinical, cold, very highly professional staff who never once acknowledged my fear or pain.   I had all my fingers and toes crossed that you would respond to me as a human, acknowledging my struggle. This is what your tears did, you needed no words. You connected with me as a human. So Hilton, I do not write this to convince you that you need not question yourself but to give my perspective of what your tears symbolized for me. I am blessed to now be able to call you   my doctor  . Sandra :)  IN THE 2010S  I was the freshly minted oldest doctor in town. The senior doctor in the clinic had just retired. My patients were growing older with me. Many of them had chronic complex medical conditions for which there was no cure and often little to I could offer to ease their suffering. I hoped that my presence may offer some relief.  International Journal of Whole Person Care  Vol 11 No 2 (2024)     22     Not with a bang, but with love and gratitude Hilton Koppe   More and more of my patients were dying. Not due to neglect on my behalf, but because it was their time. I had to work harder and harder to make sure that their ailments were managed as well as possible. To ease their suffering. And to keep them alive. I did not always succeed. It was exhausting. The pressures started to take their toll on my own wellbeing. I developed chronic neck pain. My sleep, when I wasn  t awake in pain, was infiltrated by dreams of my patients. I started to dread going to work. I had never been like this before. I sought medical attention for myself and was blessed that my doctor had the courage to tell me what I knew deep down but didn  t want to believe,   You  re done Hilton! You  ve got PTSD. You need to have a break from work. I  ll write you a doctor  s note in case you need it when you speak to your practice manager.   This is to certify that, until further notice, Dr Hilton Koppe is unfit for duties as a general practitioner. As I trudged from my doctor  s office with sick note in hand, I wondered if I had become the embodiment of the protagonist in the final lines T.S. Eliot  s poem, The Hollow Men:   This is the way the world ends. Not with a bang but a whimper.   The diagnosis of PTSD was both a relief      do I get to rest now?      and a trauma      if I can  t be a doctor, then what am I?   I was faced with a choice. A very important choice. Do I follow my wise doctor  s advice, or do I soldier on in the way medicine encourages us to be impregnable and invincible? I chose the road less travelled, and stopped working as a family doctor. This decision was accompanied by feelings of guilt and shame. Fortunately, I  d always had a parallel career in medical education, and I was able to retain some sense of work-related meaning by continuing my teaching roles. There were other benefits from being a patient more than a doctor. My main job now was to get better. I walked more. I ate less. Our vegetable garden flourished. I became a pickling and preserving prince. And as if by magic, my neck pain gradually disappeared!  IN THE 2020S  As the trauma of my diagnosis subsided and the symptoms faded, I began exploring a persisting pestering question.   Why has this happened to me?   I wondered if it might be due to something more than an accumulation of vicarious trauma from bearing witness to my patient  s stories over so many years. Perhaps it was my personality    maybe the qualities which (hopefully) made me a good doctor also made me vulnerable to the impact of trauma. On bad days, I wondered if maybe I was just weak. On more insightful days, I questioned whether the experiences of my parents and grandparents and their urgent need to get away when lives were in danger may have contributed to a genetic predisposition to accumulated trauma.  International Journal of Whole Person Care  Vol 11 No 2 (2024)     23     Not with a bang, but with love and gratitude Hilton Koppe   To answer these questions, I turned to a strategy which had been helpful over the years when I was faced with other unanswered questions    reflective writing. I wrote some new pieces trying to understand what had happened. I reviewed some of my previously written pieces. Could these pieces of the jigsaw be put together into a cohesive whole? As a book? And so, One Curious Doctor: A Memoir of Medicine, Migration and Mortality was born. It was surprisingly successful. Publication was followed by requests for interviews on radio and podcasts. Emails of gratitude from former patients and many doctors appeared in my inbox. Just last week, an unsigned card arrived. Dear Hilton, I was one of your family medicine residents about 10 years ago. So many aspects of your teaching have stayed with me. Mostly about trying to be true to myself in my work. I wanted to thank you for that. I also wanted to thank you so much for your wonderful book. As with your teaching, your willingness to reveal your vulnerability was lifechanging for me. I thought I was the only doctor to experience the things you described so perfectly in your book. Especially the bits about having visions. They happen for me, mostly when I feel fully connected with my patients. It was like you found the words to express what I felt but couldn  t explain. And never felt safe to share. I am happy for you that you made the courageous decision to step away from a profession that you so clearly loved. While you may not be seeing patients anymore, you are definitely still healing others. With love and gratitude  Biographical note  Hilton Koppe is a writer, educator, podcaster and doctor living on Bundjalung Land on the east coast of Australia. He is a long-standing member of Dementia Training Australia  s GP education team. Hilton facilitates reflective writing workshops for doctors and other health professionals with the goal of deepening their compassion, overcoming professional isolation and reducing risk of burnout. The workshops have been adapted for people living with chronic and mental illnesses, as well as enthusiastic amateur writers. Hilton has been invited to present his workshops all the way from Byron Writers Festival to Harvard Medical School. Hilton  s book, One Curious Doctor: A Memoir of Medicine, Migration and Mortality, explores the personal impact of working as a country doctor. His play, Enduring Witness, is used to facilitate conversations about end-of-life care. Hilton is co-host of Dementia In Practice, a top 100 Great Australian Pod.  International Journal of Whole Person Care  Vol 11 No 2 (2024)     24