Dr Anne Biccard, Grand Old Lady of the ED

Dr Anne Biccard has spent nearly three decades working on the frontlines of South Africa’s healthcare system, much of that time in the intensity and unpredictability of the emergency department. In this episode of Awakening Doctor, Anne speaks candidly about the stubborn determination that carried her through medical school, the realities of life in the ED, and the emotional cost of always having to “be the adult in the room.”

With characteristic humour, insight, and vulnerability, she shares stories of difficult resuscitations, surviving trauma, burnout, and even a bullet to the chest, and the important role that writing, music, rescue animals, and life on a farm play in helping her maintain perspective.

We reflect on the culture of medicine in South Africa, the persona doctors construct in order to cope, and the delicate balance between detachment and empathy that emergency medicine requires.

Wise, wry, and deeply thoughtful, Anne's story offers a rare glimpse into both the visible and invisible life of an emergency room doctor. Join us for a moving exploration of what it means to care for others while striving not to lose sight of oneself.

Dr Anne Biccard is the author of three medical memoirs: Holding My Breath, Saving a Stranger’s Life, and One Call Away.

Transcript

Welcome and Introduction to Dr Anne Biccard

Dr Maria Christodoulou 0:00

Welcome. I'm Dr. Maria Christodoulou, and this is the Awakening Doctor Podcast, a space where we discover the personal stories of those who work in the medical and health professions. Join me as I explore the hopes, the fears, the aspirations, and the real life challenges of those who carry the title, responsibility, and privilege of being a doctor. Joining me today is Dr. Anne Biccard, a medical doctor who has spent nearly three decades working on the front lines of South Africa's healthcare system, most of that time in the intensity and unpredictability of the emergency department. Anne is the author of three medical memoirs set mostly during the COVID pandemic and offering a thoughtful, humorous, and vulnerable glimpse into the life of an emergency room doctor. When she's not in the ED, Anne lives with her partner on a small farm where they provide a home to a multitude of rescue animals, including a band of greyhounds known as the Snoopies. Welcome, Anne. It's lovely to have you with me today.

Dr Anne Biccard 1:04

Thank you so much. Thanks for inviting me.

Dr Maria Christodoulou 1:06

My absolute pleasure. I've been hoping to make this happen since I heard you speak about your book at the Franschoek Literary Festival last year.

Dr Anne Biccard 1:14

Yeah, that was a fun meeting.

Dr Maria Christodoulou 1:16

Well, hopefully today we can get you to talk a little bit more about yourself because that's something that I'm interested in in terms of this conversation.

Dr Anne Biccard 1:23

Okay. She said slightly weary.

Dr Maria Christodoulou 1:28

Yes, I know. I'm quite aware as we're speaking that there's a number of factors at play here. One, we're not in the same room. Two, we're not seeing each other because you're driving as we speak, and that there's always a little bit of an awkwardness at the beginning of such a conversation. We never really know where it's going to go and what we're going to end up talking about. And there's that risk of exposure and vulnerability, but we'll feel it out and we'll find our way. So you tell me, where should we begin to tell your story?

Medicine Rewards Competition Over Teamwork

Dr Anne Biccard 1:57

Well, I've been giving some thought to what we discussed at the Friendship Fair about the kind of culture of medicine. And the thing that stands out for me is that I think in terms of my personality, I'm not necessarily the kind of person who would have done medicine from school. And I think what's quite different about my personality is that if anything, I'm a team player to my own detriment. I will put the team ahead of what suits me at any time, instinctively. And I think that medicine is an intrinsically very competitive thing to get into. And people who aim to get into medical school and then get into medical school are much more competitive in their natures than I think I am. I think that that's a huge difference between myself and the doctors that I work with. And I don't think that we're really encouraged to be team players at medical school at all. And I think that the ethos in medicine is that no one's going to help you when the wolf comes to the door. If there's trouble, it's going to be you on your own who's going to have to answer for it. No one's going to help you. And so the next sentence or the unspoken sentence is then why should we help anyone else? Not in terms of helping people, like saving their lives or being attentive doctors, but in terms of competing with other doctors.

Dr Maria Christodoulou 3:21

And what do you think that's about? Why do you think it's that way?

Dr Anne Biccard 3:24

Well, I think that you don't get into medical school unless you are academically competitive to start with. And certainly the culture of medical school, when I was there, which was 30 years ago, so it may be very different now. But when I was there, the culture was you take the book out of the library so nobody else can read it.

Dr Maria Christodoulou 3:44

Yes, I remember that actually.

The Long Road Back To Medicine

Dr Anne Biccard 3:53

You remember that, hey? I remember thinking at the time this is bizarre, because I was always very interested in medicine from when I was little. But at school, I was not very good at maths and science. In fact, I was astonishingly bad for a reasonably intelligent person. English was always my first love. My mother's an English teacher, so I was good at English, and that was my thing. But my parents were very clear to point out that you had to actually earn a living and not just fool around. So there was no career in doing English literature. Well, aside from teaching, which I didn't want to do. So initially, I actually went to university to do law. That was my initial plan. But after two years of doing legal theory, I decided that definitely was not for me, which is a good thing because I definitely think it would not have been for me. So I majored in English law and psychology, and then thought psychology would be the thing for me. So I did an honours and then a master's in psychology. And then I thought psychology was definitely not the thing for me because my basic love was medicine. And I'm too much of a fixer, which I kind of luckily had a few people who taught me in the psychology department who said to me, I'm not entirely sure that you fit the role of being a therapist because you can't actually tell people what to do. So then I took a year off and traveled and actually went out to dinner with some friends who... the lady was, we sat down at a restaurant with a bench seat thing. And as it happens, we ended up sitting opposite each other. And there was a bit of a lull in the conversation. I thought I'd have to make some conversation with this person. So I said to her, What do you do? And she said, I'm a doctor. And I said, Oh, I should have been a doctor. And in that moment, I was like, Am I going to spend the rest of my life saying that's what I should have done? Or am I going to bite the bullet and go back to medical school and start all over again? And in that moment, I thought I might have spend the rest of my life thinking of what I should have done. I'm never going to be happy or feel successful. So I went back to start first year. By then I was seven or eight years older than everybody else. Huge difference between the age of 18 and 24, let me tell you. It's remarkable to me. I mean, my clinical partner who I'd been working with for two years, so overexcited because she got her driver's license. And I was like, Your driver's license? I was like, how have you been getting around? She says, My parents bring me to medical school. I was like, what? Your parents bring you here. I mean, by then I'd been living independently for six or seven, eight years. So to me, the notion of my parents telling me I wasn't allowed to go out during the week because I had to study was remarkable. And also because I was working then, I worked as a paramedic to pay my fees. So when I wasn't in medical school, I was working. And that was eight years of my life. When I came up for air, I thought, where have the last eight years gone? Disappeared without a trace.

Dr Maria Christodoulou 6:49

Where did that love for medicine come from? Because you said my first love was medicine, and where did that grow?

Dr Anne Biccard 6:55

I'm not sure, you know. I remember we had a book called The Family Doctor, which was quite a tome, sort of a thickish book, lots of um anatomical drawings. And I was totally fascinated by that book. I had memorized that book in its entirety by the time I was about 12. I could tell you every kind of disease, every kind of symptom, where all your organs were. I just was fascinated by that book. I'd go and take it off the shelf and read it with great enthusiasm. I think there's that, and then there's the psychology of being a fixer, which is if something's wrong, you want to know how to fix it. I think it was a combination of an intrinsic interest in the human body and a need to know what you can fix and then to be able to fix it. And then because I'd been working on an ambulance to pay my way, I thought I would become a trauma surgeon, which I'm very, very glad I didn't become because that is a jealous mistress.

Dr Maria Christodoulou 7:58

That's an interesting way to describe it.

Dr Anne Biccard 8:00

Yeah, yeah. I can tell you it's got you by the whiskers and it's not letting you go anywhere. You basically have to make a commitment to that job, and you can't have any other interests.

Dr Maria Christodoulou 8:11

And the eight years of studying medicine, what was that like? You went to Wits University, right?

Dr Anne Biccard 8:19

Yes, so I went to Wits. In fact, it's interesting because I applied for medicine, and when I got a letter accepting me after the interview, in my head I was already a doctor. I just had to do the time. There was no question in my head that I would manage to sustain myself, pay my way, study, pass the exams. There was never a second thought in my head. It was a done deal. I think that that's a way to get past obstacles, is to never allow yourself a moment of doubt. I mean, my family said to me... My parents died when I was 18, so basically I didn't have anyone who was going to support me at medical school. I had sort of extended family or cousins and aunts and uncles said, How are you going to pay for this? And I was like, I'll make a plan. There was never any doubt in my head that I was committed to it and that I would pass, and that it could happen. I just had to do the time. There was never a question. And interestingly enough, of course, you know, you have to go back to first year and you have to do physics and chemistry. Which, if I wasn't good at eight years before the fact, after eight years of certainly never thinking a scientific thought, I can tell you I was so resoundingly bad at it that we did an entrance exam to gauge the level of the class. And it is the one and only exam I've ever failed in my life. And I failed it with something like 12%. And the guy who taught me physics said to me, if you had randomly chosen, you would have done better. On the luck of the draw, you would have actually got a better mark. Why didn't you just guess? Or just put all A or all B. He was a great teacher, I have to say. He was an older man, and I think it was his last year or so of teaching, and he really did not like medical students at all. He had a kind of particular loathing for us all, which he expressed very cleanly in our first lecture of how he thought we were all pseudo-scientists and arrogant and he hoped we all failed basically. And he had this office, because you're on main campus for your first year, he had an office there and he had to put up times that he would consult. And he made his times between four and five on a Friday afternoon because he thought nobody would come at that time. But little did he know that I was going to pass that subject come hell or high water. So I went to see him every single week during his times, and we went through past exams, and he just looked at me with this look of I can't believe how dumb you are. But then he was slowly goaded into teaching me because he would say to me, But why do you think that? And I would give him some convoluted reason, and then he would say, No, no, but your reasoning is not correct. Anyway, the long and short is I ended up doing extremely well in that subject. And he actually came to my graduation after he'd retired, and he waited for me outside the hall, and he said to me, I want to tell you, you are the most determined student I have ever encountered.

Dr Maria Christodoulou 11:32

You've spoken about that stubborn determination in your books as well, and I'm curious about that. Where does that come from?

Dr Anne Biccard 11:39

Yeah, I don't know, I think it's genetic. My brother's also got that stubbornness. I mean, I try not to be stubborn, but it's just intrinsic. Everybody thought that I would become a psychiatrist because I did psychology first. And I'm like, I'm too stubborn to be a psychiatrist. If you try and make me do something, I just won't do it. It is a bit of a fault, but I try not to let it take hold of my life.

Determination As A Survival Skill

Dr Maria Christodoulou 12:03

And losing your parents at 18, I imagine that kind of been easy.

Dr Anne Biccard 12:07

Yeah, well, they were both not in good health, which is the obvious reason why I wanted to do medicine, but actually I don't think is the psychological reason that I did medicine. Although my mother actually died of a bleed in her brain, which is very unlucky. She was only 49, so she was young. And I think she very kindly gave me that gene since I had my blood pressure measured a few years ago, and I was like, ah, that machine is broken. And then I checked it again on another machine. I was like, oh, I wonder if this machine is broken too. And then I was like, no, that's actually my blood pressure. Well, that's a nice gene that I got from clearly every woman in my family who died before the age of 50, because they obviously had un diagnosed very high blood pressure. So I was like, ah, thanks for that.

Dr Maria Christodoulou 12:53

You know, it's funny you talk about that because one of the things that I remember about listening to you at the literary festival last year was you mentioned at some point, in a quite self-deprecating manner and very nonchalant way, you said, ah, doctors are notoriously bad at looking after their own health. And I was dumbfounded because nobody questioned it. There were what, maybe 200 people there? No one looked confused, no one thought, well, really? Is that true? Or why is that true? There was just this consensus. Yeah, we all know doctors are notoriously bad at looking after their health. And I found myself reflecting for a long time afterwards about why that is.

Dr Anne Biccard 13:34

Oh no, we're shocking. Funnily enough, one of the more senior doctors at Linksfield, who's a surgeon and is actually a dear friend, said to me, Don't be an idiot like all other doctors. Go and see someone. And I was like, So who am I gonna go and see now? I mean, all of the cardiologists, who's the person you'd see basically, to find out why you have such high blood pressure. They're all friends of mine. I'm not gonna go there and make an appointment, then I'm going to have to take off my shirt, they're going to do an echo. Uh, I'm good, thanks. So then I'd have to go to a different hospital. Then you have to take on the whole role of being a patient and oh no. You know, you just think, ah, what are they gonna do? They're gonna put me on medication. Everybody says, see a doctor. I'm like, I did, I saw one this morning in the mirror.

Dr Maria Christodoulou 14:17

Yes, and then you do what all of us do, you prescribe your own medication.

Dr Anne Biccard 14:20

Exactly. I did actually go and see a cardiologist, though, just because my friend Wolf hounded me so much.

Dr Maria Christodoulou 14:27

So you finish medical school, and then... actually, before we go there, I want to backtrack a little bit because I've read two of your books and there were a lot of things in those books that stayed with me. And so I'm curious about them and I want to ask more questions about them, and maybe in line with this idea of doctors are notoriously bad looking after their own health. There was a place in the book, the latest one, One Call Away, where you talked about those 10 years of putting your head down and doing what you had to do to get through medical school and finish your two years of community service and come out on the other side. And how when it was finally done, you then still had to work for another four years, and that there was this moment when you were finally on a break where you looked up at the sky and thought, where have I been for 10 years? Like, what have I lost out on in having devoted myself so determinedly to this task? And I'm wondering when you think about that today, what does that bring up for you?

Dr Anne Biccard 15:25

Well, I think that there's a price to pay for anything. And those moments of reflection of being kind of in the universe and looking at the sunset and looking at the stars and the familiarity of different constellations and things, that's a quiet space. And I didn't have the chance to be in that space during the time that I was at medical school because I had to just keep running. I just had to make a plan to stay alive, basically. All of my free time was used studying or pursuing that. If I finished exams, that night I would have my first night shift because I haven't had a night shift to work for a month because I've had to write exams, so I can't obviously work at night. So then it's like you jump from one thing to the other and you kind of plan it with no space in between. And I think partly I planned it with no space because I genuinely was motivated, and partly because there is part of one that thinks when you stop and reflect, you may not start again. So if you take a break and you think about what you're doing, you might say, actually, is this worth it or whatever? It's like you can't think about it. It's a bit like, you know, people in the ED. For a while, they wanted to have a post-traumatic stress counselor come and speak to us after we had a difficult death, like a drowning, or whatever. And I was like, actually, that would not be helpful for me because my defenses are there for a reason. And I have to pick up the next file and see the next patient. I can't actually just fall apart. And if you want me to speak to a counselor, I'm not gonna be able to just pick up the next file. My defenses need to be there because I need to do my job. I mean, for a long time I was seeing a therapist, and I said, you know, actually, my place of work should be paying for this because all I ever talk about is work. So it actually really irks me to pay a therapist, and all I do is talk about how traumatic my job is. You know, I'm gonna have to see you on Monday morning first thing if I don't work on a Sunday, because otherwise I have nothing in my head other than the last five days of resuscitation.

Dr Maria Christodoulou 17:35

So why emergency medicine?

Dr Anne Biccard 17:37

Just where I ended up. When I qualified, there wasn't a speciality in emergency medicine. And if I had to have my medical career again, I probably would have done something like orthopaedic surgery. Because I'm good at fixing stuff and I've got good hands and I build things and I probably would be better suited to that. But I just ended up working at an ED and then you work there, get good at it, you get more work there. If I'd kind of thought it through as a speciality, or certainly if I had to do medicine again now, I wouldn't do emergency medicine as a speciality. I mean, I don't think there's much for any kind of independent practice. You essentially have to be employed.

Dr Maria Christodoulou 18:14

True. Yeah, I hadn't thought about that.

Dr Anne Biccard 18:16

So yeah, I'd probably either do anaesthetics or orthopaedic surgery. And I probably wouldn't do anaesthetics because you're too beholden to the surgeon. I mean, now anaesthetists have much more of a voice. They will say, sorry, but there's too much blood loss, you have to stop operating. But in my day, the anaesthetist just doped the patient and kept quiet. They had absolutely no say over the actual operation. The surgeon was the person responsible, and he - mostly he - got to make all the decisions and sure, takes all the responsibility. That's the other side of it. But now anaesthetists co-manage the patient. I mean, I went to go and help with a patient that had a haemorrhage after having a problem with the placenta. The placenta was sort of enmeshed into the uterus lining and the patient bled profusely from a caesar. And the anaesthetist was having as much input there as the surgeon was. They called the ressus, instead of being a passenger, they were actually as much of a driving force. So I think that's a good thing that that's changed. But certainly when I qualified, you'd have to get a list, you'd have to be polite, if a surgeon's rude to you, you just suck it up. Because at the end of the day, you need to work. And that doesn't really suit me.

Becoming The Adult In The Room

Dr Maria Christodoulou 19:31

You're highlighting something about medicine, which is the different stereotypes and the hierarchy in medicine. Something I've been curious about is how we construct this identity of the doctor. What does it mean to be a doctor? Who is the doctor? And what it takes to put up that mask or that persona of being a doctor, often at great cost to one's personal self. I guess I'm wondering about the persona that you've created. You do say in one of your books that that persona is quite close to your actual character and self. But there was a lovely section which I'm going to read because it really stayed with me. You said, What I am is an actress with a dark sense of humor. I use distraction and detachment to distance myself from the pain and panic of my everyday job. But there are still some patients who move me to tears and some situations where I cannot belittle the pathos and sadness that abound. I have enmeshed myself along the way into the persona of the grand old lady of the ED. It is inherent in the nature of a consultation that I am invisible. And after years of no one seeing me, I no longer see myself. What's it like to hear that?

Dr Anne Biccard 20:45

I'm like, I wrote that, shit.

Dr Maria Christodoulou 20:47

Yes, yes, you wrote that.

Dr Anne Biccard 20:51

It is exactly what I think. I mean, I do think sometimes I'll joke with people and there's a kind of realness in a consult. But I think that one of the big things in medicine is that patients don't really want to be there mostly. So they're not there to have tea and socialise and be nice to you. Mostly they're there because, well, obviously they're there because there's something wrong. But it's not something that they anticipated. And quite often, if they're afraid or in pain, they regress in psychological terms. So they behave like children. So when you ask me what is it to be the doctor, I would answer that by saying you have to be the adult in the room. And that is not always easy because when you're a young doctor, most of your patients are older than you, to start with. So you are dealing with a demographic of people who should really be in the parent or sibling category, and yet you are actually the parent there. So it's taking on the responsibility of being the parent. You don't allow your real personality to be in the room because you can't do that. You can't allow yourself to go into the rabbit hole of what you really think or what you really feel because that's not what your job is. If you allow yourself to let your emotionsruntheshow, yogoou're got gninna r'i nto truouble . You're not going to make the right diagnosis, you're going to get into conflict with patients. If they shout at you, you're going to shout back at them. You have to just step out of the room as yourself and be a particular persona. And part of that is being an actress because nobody wants the doctor to go. Somebody comes running into the casualty saying, Oh my god. You can't go, oh my god. It's not going to be helpful to anybody. But if somebody's screaming, you just want to scream back.

Dr Maria Christodoulou 22:47

What stops you from screaming back? What stops you from going, oh my god?

Dr Anne Biccard 22:51

The person wants to think you know what you're doing. And you have to pretend that you know what you're doing, even if you know that you don't know what you're doing. It's very difficult to say to a patient, I actually don't know what's wrong with you. I often say that if I don't know what's wrong with something, I'll say, I know that it isn't anything serious. You're not having a heart attack, you're not having a pulmonary embolus. But why exactly you have chest pain, I actually don't know. We've done all these tests, these are the things I've looked for. I can't find anything serious, but I don't actually know what's wrong with you. And if you say that and you've kind of given it due diligence, most people accept it. But if you say it without doing the due diligence, then patients get really irritated. If you just shrug your shoulders and say, Well, I don't know. It could be anything. How would I know? They don't want to hear that. They want to hear, you know what you're doing, you've checked for everything. I mean, how do you check for everything? People say, Have you checked for everything? I'm like, what check is for everything? There is no check for everything. I've checked for what I've thought of. And if it hasn't cross my mind, then I haven't checked for it.

First Shock Losses In Hospital Life

Dr Maria Christodoulou 23:50

Was there ever a time when you struggled to stay an adult, when you did lose it?

Dr Anne Biccard 23:55

Well, one of my first resusces ever as an intern was a... So just as some sort of background. Obviously, I'd been working as a paramedic for a good number of years. I actually started doing that even before, when I was still doing psychology. But I did it as a volunteer basically in what used to be called civil defense. You could go along to the municipal fire station, as it was, and join there as a reservist, which I did when I was 18. Much to the horror of all the then firemen who now had to put up with a girl in their midst. But I did that voluntarily and did all the qualifications through them. And then when I went back to medical school, I got a job at a private ambulance company. But obviously, the one thing you know as a paramedic is how to do a resuscitation. So I wasn't ever the person at medical school that worried about that because I hands down had it taped. But then when I was an intern, we had a chap who came to the public hospital where I was working, and he had appendicitis, so we took out his appendix. He was a young healthy guy, like in his 20s. And sent him home and he came back, he had an infection in his wound, and we readmitted him and essentially he was for antibiotics and supposed to go home the next day. And it was visiting hours and, you know, when I was a medical student, one day you're a medical student, the next day you're the doctor, and you just suddenly, you're it, you have to make the decisions. There was no one to help us. The registrar was in theatre, and you were on the floor. Basically, if they came on a stretcher, you admitted them, and if they walked in, they walked out. That was literally the science to it, you know. And half past eight comes, and I go past this guy's room, and I see his family still there, and I say, I think it's the end of visiting hours. And he says, No, no, I've asked my family to stay because I'm worried I'm going to die. And I said to him, No, man, why would you be worried about that? Everything's going well, everything looks fine. He was like, No, no, there's something wrong. I'm going to die. So I said, Look, I'll take some blood to check. We'll do some blood work just to check everything's still fine, but your bloods this morning were fine. And while I was busy setting up the tray to take the blood, he sits up on the bed and he just vomited this bright red arterial blood all over his family, all over me. And I just stood there and I was like, oh my god. And then he arrested. Then he fell off the bed, and so he was on the ground. So I said to his family, help me get him on the bed. I started CPR and I pushed the bell and everybody came to help me. And I was like, something's gone wrong with the surgery. Like, all I was thinking was he's broken down... Because they did an anastomosis because he had a bit of a septic bowel. The anastomosis is broken down, we have to get him back to theater, but we couldn't get him back, we couldn't resuscitate him. And I just remember I was panic stricken, because I'd said to him, like, there's nothing wrong with you. And then as he vomited this blood, there was just this moment of like, oh my god, there is something seriously wrong. And then I thought, he's arrested. Oh my god, he's arrested, you know. And then I started CPR. Anyway, it was an unsuccessful resusc. But then we had to do a post-mortem, obviously, because it was an unnatural death. And I had to go and do the post-mortem, and I've known this guy, and I was like, I don't know if I'm cut out for medicine, you know. I mean, his wife was there with like a one-year-old baby. He was a young guy, and what actually happened was that with all the stress of having the appendicitis, he had a huge ulcer on the posterior wall of his stomach and it eroded into his aorta. And so there was like nothing that I could do about it. I mean, there was nothing that I could do in retrospect. Like when we went through the post-mortem, I was like, okay, well, even if we'd been in theater and had two drips running with blood, if you bleed from your aorta, that's the end of you. There's nothing we could do, you know. But I remember there was just this moment when your kind of assessment catches up with... Because you're kind of in denial. You're thinking, ugh, what could go wrong with this guy? He's not septic, his tummy's soft. I didn't quite talk him down, but I was like, oh, you know, you're just anxious, don't worry, you've had two major surgeries in a week. It's just a bit of like coming down from the anaesthetic, don't worry about it. Because he was like, I just feel so restless. I just feel like I'm going to die. I'm like short of breath. I'm like, no, but your sats are fine, you know, there's like nothing to worry about, your chest is clear. Like I was reassuring him. And meanwhile, his aorta was bleeding. So that's a bit of a moment of like, oh my goodness. Like I wouldn't even really call it a misassessment. It was more, I just didn't see that coming.

Why The ED Still Pulls You Back

Dr Maria Christodoulou 28:16

I guess I'm also curious about what keeps you going, what keeps you working in an ER when you have one story after another along that vein, where you're losing people on a regular basis, where the things that are happening to them are often beyond your control?

Dr Anne Biccard 28:30

Well, it's a funny thing with human nature. You always remember the bad stuff. You can save 100 people, and then one comes along that you don't save. That will be the one that sticks with you. You don't remember the other 99 that you did save. I think it's the human condition. Maybe we have to be more like wary of stuff that goes wrong, because we have to remember that stuff in our primitive brain so we don't get eaten by a lion or whatever it is that we try to guard against. And so you... The one save, the one point you get against the Grim Reaper, that sort of energizes you for a little while. And then if you have like recurrent stuff that goes wrong, you just think, uh, maybe it's time to leave. Maybe it's time, maybe I've had enough of this. But you can't just leave. I mean, you made a commitment to being there and you have to be there for another few times at least, or another few months at least. You can't just walk out. During COVID, I definitely considered can I just walk out the door and never come back? But you can't do that to your colleagues, and you can't do that to your patients, and you have a responsibility to do what you said you'd do, and then by the time you can think of a way to get out of it, you've kind of got past that. You can't just make the decision on the spur of the moment.

Dr Maria Christodoulou 29:46

There are doctors who walk away.

Dr Anne Biccard 29:48

But I don't think that they walk away like I'm not coming to my shift tomorrow.

Dr Maria Christodoulou 29:52

No.

Dr Anne Biccard 29:53

I think that you would say, I think I need to take some leave or I need to maybe change where I work. But you'd give the person some notice. You wouldn't just walk out. Well, I would try not to do that to my colleagues. And that's because I am a team player. That is making sure that all the doctors on the shift have food and a little something left out for them. Like this morning, my colleague sent me a message at 10 o'clock last night saying he had an emergency, please can I come in early? I'll not go to gym or do whatever to help them because I think about him there at night on his own. And I'm first of all deeply grateful that he's doing the night shift. And secondly, I have great empathy for being the only doctor there that everybody's got a lot to say about, oh, you know, you went too slowly and didn't see the patients quick enough. Well, why don't you work the night shift and see how quickly you go? You know, it's all very well in the light of day to say, oh, but this X-ray was abnormal. But you're there looking at the X-ray with tired eyes at two o'clock in the morning on your own, they should just be grateful somebody's doing it.

Dr Maria Christodoulou 30:56

You mentioned the Grim Reaper a moment ago, and you write about Grim in your books. I was curious about those moments when you know that Grim is in the room.

Dr Anne Biccard 31:08

Yeah, it's a funny thing, you know, the other day I was thinking, not only when you know that that is pending, but something happens when people die that leaves some residue on your skin. And I actually said that to the Sister. I was like, now I have to get this off my skin, and it's going to take days. Like something rubs off from them on you. In their transition, something happens to me as the person who's attending to them. And there's not much I can do to avoid that, but there is definitely, I don't know whether you'd call it an energy or a I don't know what it is, but it gives you a particular feeling. And it's not sadness, because even if it's not a sad death, you know, if it's time for the person to go and it's actually almost like a palliation, it still leaves a residue. You can't, what are the words of that poem, go gently into this dark night. I don't think such a thing exists.

Grim Reaper And Guardian Angel Moments

Dr Maria Christodoulou 32:02

So there's the Grim Reaper on the one hand, and then you also mentioned in one of your books the Guardian Angel, and you talked about a number of incidents in your life, and you kind of glossed over them in the book. And I was like, What? You talked about jumping off a moving train, you talked about being flung out of a truck, you've had an encounter with rabies. Tell us a little bit about those things.

Dr Anne Biccard 32:24

I must say that my guardian angel, there's a picture of a guardian angel with its head on its hands and its wings sort of slumped. And I think that my guardian angel must be that person because if I just think of the sort of chances and...Both winning chances, you know, like riding motorbikes and just doing things that I look back on and think, okay, I was ridiculously lucky that I survived that with pretty much almost no injuries. I was driving in an ambulance with two guys, and I was sitting in the middle, and the guy who was driving the ambulance went through a red robot, and a car was coming on a crossroad, and it was a blind corner, and the car hit the ambulance, wrote off the ambulance, hit it side on. And because I wasn't wearing a seat belt, I flew through the windscreen. And there I was sliding along the road, and the ambulance was rolling next to me. And every time the ambulance rolled, it like jumped up in the air and it went over me, and I was like sliding along the road. And I just remember thinking, what am I doing out here? Like, how did I get from inside there to being out here on the road? You know, it was just like noise and light. I mean, this resounding smash. I literally walked away from that unscathed. I mean, I needed a lot of stitches, but I didn't break anything. It was like the universe just said, not yet. And the same with the home robbery that we had when I got shot. I was like, this guy broke in through the door, and as I put up my hand to close the security door, he shot me in the chest. And I was like, that guy just shot me. I was like, why would somebody shoot me? My exact thought was that I'm a nice person. Why would he shoot me, you know? Because I mean I've never had an interaction with anybody who would want to shoot me.

Dr Maria Christodoulou 34:09

That must have been terrifying. It was bizarre. And just like this incredible humming in my body, my whole body was like a swarm of bees. I mean, that group of people literally murdered all of my neighbors. The police were less than interested. Because, you know, farm attacks, they're not about to go and get involved there because they're definitely going to get shot at, so they just leave the thing. So this group of guys that were robbing everyone eventually went along to the police station and held them all up and stole their car and all their guns. And then the general, who was there to deal with the massive crime problem in the area, he was so outraged that they had stolen his bodyguards things that he called a chopper and they cordoned off the area and eventually they caught the guys. But only because the general was so annoyed by the slight of having his bodyguards and everybody else robbed at gunpoint in the police station. That was just too

Shot In The Chest And Learning To Walk

Dr Anne Biccard 35:08

much.

Dr Maria Christodoulou 35:08

What's it like for an ER doctor to be on the receiving end of emergency care?

Dr Anne Biccard 35:13

It was quite hectic because, of course, Alida, who I'd just got involved with, said, must I take you to Linksfield? And I obviously couldn't walk because I was paralyzed. I said, No, take me to Milpark, because Milpark is a trauma unit. But obviously we couldn't phone because the guy stole our phones, and she didn't know where Milpark was. So she dragged me to the car and put me in the front seat, and I put my legs up on the dashboard to conserve my blood volume.

Dr Maria Christodoulou 35:37

So you've been shot in the chest, and you are making your way with the help of your partner to your car to drive yourself or be driven to a hospital.

Dr Anne Biccard 35:45

Yes. My advice to anybody is don't wait for the ambulance if you don't have to. Just get in your car and go to the nearest level one hospital. So I was like, turn left, turn right. And then I was like, yoh, you know like when you know you're going to lose consciousness, and everything starts to go like dark. I was like, I think it's this road, just follow the signs. So we're like one minute away. And then we pulled up there and Alida ran in, and as it happened, the trauma surgeon, who's a guy called Riaan Pretorius, he happened to be in the unit, so he ran out of the car, literally picked me up out of the car. By that time I was pretty much at the end of my tether, that's the wrong word but... So basically he resusced me and put in the chest drain, and I mean I was fine, I was in ICU for 10 days, but I couldn't walk for like two years afterwards, which is a real challenge because the bullet went into my spine, which is still there. The fact is, I walked away from that, literally, well, I dragged myself away from it. So my guardian angel obviously was paying attention then.

Dr Maria Christodoulou 36:49

What was it like to be paralysed and to have to learn to walk again?

Dr Anne Biccard 36:53

That was so interesting. People were like, oh, you know, I wouldn't want to have lived if I'd been paralysed. This is about me, because I'm such a physically active person. It never crossed my mind that I didn't want to live if I was going to be paralysed. But also, I was like, oh, this will go away. Actually, there and then when I was shot, I was like, oh, I can't move my legs. Literally, I was like, oh shit. Well, sorry, you should take that out. Edit that phrase out. But I was like, oh no, this is... Well, first of all, that guy just shot me. Why would you do that? I mean, if you'd said to me, give me your phone, I would have given him my phone. I wasn't gonna fight about it, you know. And secondly, I was like, oh, I can't walk, so this is a problem. So I was just like, I'll recover from this. I mean, it has been very frustrating because before that I was a very good sports person. I was in the gladiators and I played first league squash and I was very physically active. And two years of not being able to move your one leg, you get wasting of your muscles. And so then when you try and run again, you actually can't do it. And it's not that you don't want to do it or are not determined to do it, you actually physically can't do it. Neurological injuries are very frustrating because it doesn't matter how much mind over matter there is, there's still a problem with your nerve tract. And you can pretend it isn't like that as much as you like. When you try and stand on your toes, your one foot just doesn't work. So it was a challenge, to put it mildly.

Dr Maria Christodoulou 38:25

I was going to say that, yeah, to put it mildly is probably a good way to describe it. I do have a question on my list that asks about what are some of the turning points or life-defining moments that you've had over the course of your life and career. I imagine this was one of them. Are there any others that you might consider to be turning points or life-defining?

Dr Anne Biccard 38:48

Well, getting into medical school was a life-defining moment, definitely. The discussion I had with one of the psychologists that used to work at Wits about whether psychology really was the right choice, that was also life-defining. I think a lot of people aren't properly counselled about their careers. Certainly in medicine, you decide you want to become a surgeon. Certainly when I qualified, there weren't many people who wanted to become a surgeon where the surgery department looked at them and said, actually, you're not suited to this job. And I mean, I had a person job-shadowed me for a while and then came back to medicine, and he said he wanted to become an anaesthetist. And we had a resus in the casualty and he just froze. And I was like, I don't know if that's a learned response, whether you can learn to act. But anaesthetists need to act when they have a thought. Like the blood pressure is too low or the airway pressure is too high, they have to act on it. They can't be a passenger. I mean, I think that that's a particular kind of personality. I'm a much more cautious person. I wait and see what's going to happen next. That's not the right personality for an anaesthetist. You don't wait and see. And also for an emergency medicine physician. I mean, sometimes they jump in too quickly, like let's give blood. I'm like, well, let's just wait for the Hb first. I mean, I had an interesting interaction when I went on holiday with some friends, and we were staying at a cottage, and we got there after hours. We brought the stuff in from the car. It was one big sort of bungalow, so there were four of us in separate beds in this bungalow. And I was the last person to come from the car, so I know that I'd locked the door. And this guy came to the window, and he looked in the one window, and I was like, there's somebody outside, but I'm going to wait and see what happens. And then he went around to the other window and he looked in through that window, and that person who was sleeping in that bed woke up, saw him through the window, and started screaming. And so, of course, he ran away. And I was like, Okay, now you've chased him away. Now we're not going to know what his intention was, and now we have to wait to see if he's going to come back. And she said to me, Are you crazy? Why didn't you do something about it? I was like, I was waiting to see what he was going to do. She was like, But if you wait until he breaks the window, he's more committed to the wrong course. So how can you wait and see? I was like, maybe he was just looking in through the window. I know the door is locked. I'm awake, and I'm certainly thinking of what I can use as a weapon, but I'm going to wait and see what he does next. And that's just my personality, and it's actually not a good personality for a person like an anaesthetist.

Dr Maria Christodoulou 41:31

I find myself wondering if you ever get scared because the way you tell the stories, it sounds like you remain quite pragmatic in fairly terrifying situations.

Dr Anne Biccard 41:41

You know, there's an energy to it. I mean, the other day I heard these running feet in the corridor. I was with a patient, and I was like, they're going to call me now. They're going to call me to resus now. I just know. There's like an energy of the way people move. But not 10 seconds, they're like, Resus. I'm like, oh, I knew you were going to... It's like I wouldn't call it fear exactly, but it's apprehension. It's like well what now? And also, I mean, there's certain things that I just hate, like drownings of children. I just... I hate that. It's just awful. A lot of emergency medicine physicians are like, oh, they like a bit of action, you know? I'm like, no, the less action the better. I don't want to have to do CPR on people if I don't have to.

Dr Maria Christodoulou 42:28

Anything else you would consider life altering, life-defining turning point?

Dr Anne Biccard 42:32

Nothing that I can think of offhand.

Dr Maria Christodoulou 42:35

What led you to start writing?

Writing To Process Trauma And Teach

Dr Anne Biccard 42:37

Well, I left Linksfield because the guy I worked with for a long time actually stopped running the practice there. So I missed my community and my work. So I thought I'd just start writing it down. Like a catharsis kind of thing. I actually really wanted to write it kind of more like a textbook, but of like, you know, how do you go about being a doctor? Not really like doctors for dummies, but you know what I mean, like more hands-on kind of how you make an initial assessment of a patient. Like what you see, what you smell, what you hear. I think they might teach that now at medical school, but they certainly didn't teach it when I was at medical school. So I started kind of writing about that and then it turned into a story. And that's the thing about the casualty, there are lots of stories. And there's a lesson to learn in each story, and once you've learnt that lesson once, you tend to teach it on to the next person. The one guy that I worked with, like, how do you put up with teaching junior doctors? Don't they just drive you crazy? And I was like, Well, don't forget those people are going to be resuscitating us and our families when we old. So you better make sure you teach it properly because they're going to be relying on you. And also remember what it was like to be a young doctor, you didn't know what you're doing. I mean, there's nothing worse than knowing you don't know what you're doing, nobody else in the hospital knows what you're doing, but you know things are about to go seriously wrong and you don't know what to do to prevent it. I mean it's a question that they ask on most resus courses. If you'd known ten minutes ago that this patient was going to arrest, what would you have done differently? And that's all very well, I would have checked their potassium. But now it's a bit late, you know? So it's those kind of little life skill things. Did you think of this? Did you think of that? If the patient's got epigastric pain, have you actually examined them? And even a patient with chest pain, did you actually put your hand on their stomach? Because acute cholecystitis can look a lot like an MI. You know, you send the patient to the wrong person, it just delays everything. So little things like you can't get away without examining the patient. As much as you actually really would prefer not to put your hands on them, especially in COVID, you prefer not to even go in the room. You actually have to touch the patient. If you don't touch them, you are not going to make the diagnosis. You have to get a good history and you have to examine them. Even if you only examine the organ system that they're presenting us. I used to joke in government because everybody writes NAD for no abnormality detected. I'm like, no, man, you mean not actually done?

Dr Maria Christodoulou 45:10

I'm never going to think about the NAD in the same way again.

Dr Anne Biccard 45:13

That is actually what you do. You're too busy, you don't have a bed to put them on. You make an assumption that because they've got a cough, they've got a respiratory problem. I had a patient when I was a student who came with a cough to the gynae hospital. It's now Rahima Moosa, but it used to be Coronation. And I was like, no, but this is like a gynae hospital. You know, she's 50-something year old lady with a cough. So I literally like undid one button on her blouse to listen to her chest. I was like, oh, she sounds terrible. In the corridor, because there are no beds to examine them on. So I was, yeah, so I write a little note there to my colleague at Helen Joseph, which used to be called JG Strydom. I'm like, thank you for seeing the above, plus plus crackles and wheezes, coughing for two months, loss of weight, whatever. And he phoned me, because he was a guy who was actually at class with me, and he was like, That patient you sent with the stage four fungating breast cancer with mets in their lung...

Dr Maria Christodoulou 46:09

Oh, my w ord.

Dr Anne Biccard 46:10

And I was like, okay, well, I didn't examine that patient. I didn't take her shirt off. I just listened literally, probably through a blouse. I remember actually opening her top button. But I mean, literally posted my stethoscope down the back of her shirt, had a quick listen, wrote her a letter and sent her on her way. I'm like, oh, he obviously thinks I'm a complete idiot.

Dr Maria Christodoulou 46:29

I remember a case where, as a.. I think I was an intern, I was asked to go and examine a patient that had been admitted to the endocrine ward for regulation of her diabetes. And she'd been seen in outpatients a number of times before that admission. And when I went to examine her and I lowered her gown, she had this fulminating breast tumour that had erupted through the skin and was all over her chest. Nobody else had seen it before.

Dr Anne Biccard 46:55

Well, that's exactly because I mean the other side of it, of course, is you can't ask people to take their clothes off for a simple thing.

Dr Maria Christodoulou 47:02

And also the patient was in some denial because when I asked about it, she looked down with kind of a horrified look and went, Oh, I've not seen that before, you know. So there was a collusion in the denial, let's put it that way.

Dr Anne Biccard 47:14

Yes. And I mean, of course, if the patient doesn't tell you what they're actually consulting for, y ou don't always have the time to hunt down... Sometimes I'll say to somebody, Well, what are you worried about? Because this history is not making any sense to me. They'll say, Oh, well, my brother just died of a brain tumour. And I'm like, Oh, okay. So we actually here for like reassurance about that, because none of these symptoms fit together. Although I did have a guy once who told me that he had these weird constellations of motor and sensory symptoms. And I was like, this doesn't make sense. He was like numb on the outside of his arm, and he had like weakness in his other foot, like nothing really defined. So I snuck up behind him with a pink needle and I stabbed him on the elbow because he said his arm was numb. But I stabbed him, and a little trickle of blood ran down his shoulder, but he didn't move. And I said, Oh. I sort of dabbed the blood. I was like, okay, do you feel that? And it turns out that he actually had multiple myeloma and he had multiple level degeneration and it had collapsed in various places. So he did actually have like sensory weakness in one place and motor weakness in another. But I felt so bad because I stabbed him and I expected him to sort of go, Aargh. And he didn't even flinch. I was like, oh, maybe he is numb then.

Dr Maria Christodoulou 48:39

In the bio that you sent me, you said that writing makes you become increasingly introspective about what is really of value to you. And you've written three books in a fairly short period of time. So I'm wondering what you've discovered about what is really of value to you.

Dr Anne Biccard 48:54

I think if I didn't live far away from where I work and in a completely different environment, I think my work would drive me completely crazy. It's like the perspective that you need. So you need to have some time away from that medical intensity. So I think that that's important. Working in the ED is like an intrinsically meaningful job. Because even though you can't save everyone, you can certainly make a difference to people. You can at least give them something for pain. It's not just a routine thing of same old, same old every day without a change. So I think that the work is intrinsically meaningful. I think that the team that I work with is important. So training and helping younger doctors to have an approach to stuff is really nice. Although, I mean, I trained a younger guy for a while. He said to me, you know, I've just got one goal. I'm like, and what is that? He said, I have to learn to roll my eyes like you do. I was like, okay that's the only thing I've taught you in the last 18 months. That's a pretty sad state of affairs. So I think that training younger people is quite meaningful for me. Or at least passing on some kind of way to think about things. I tend to think sort of quite anatomically. So I'll sort of say to them, well, what could it be that would give you pain there or give you that symptom, or what could be like the worst-case scenario? And I think the team that I work with provides a lot of meaning. I know the people that I work with, they know me. When I left Linksfield, I don't know how many years ago it was, probably 2018, so eight years ago. I went to go and help start a new unit at Wilgeheuwel near me. And I didn't have the community that I had at Linksfield. I had to sort of start again with all of the doctors. And the specialists can be extremely rude, to the point of you just want to say, sorry, like, sorry, you know. I mean, the one guy, I phoned him, he was a cardiologist, not at Wilgeheuwel, he was at another hospital. And he said to me, Oh, what's the patient's name and the medical aid? So I said, sorry, the nurse has actually just taken the sticker. Can you give me a minute? He said, Oh, just like every other doctor, you phone here, you don't even know the patient's name. Now go and assess the patient properly and phone me back when you know what you're doing. I was like, uhm, sorry? Sorry? I'm like, I just sent you a picture of this guy's ECG, he's having an infarct. Look at the bloody ECG, the stickers on there. Instead of trying to call me out on something and getting on your high horse, I'm like, that is not the way to start a relationship. I was just like, yoh, uh, no, I'm not phoning that guy again. I'll send the patient to another cardiologist or a different hospital, but I'm not like, where do you speak to people like that? I would never speak to anyone like that, any staff that I work with. I would never be dismissive or say to the nurse, go and assess the patient properly and come back when you know what you're doing. I would never ever say that. It's just unacceptable. I just can't speak to people like that. He hung up the phone and I just sat there and I like looked at the telephone receiver and then I looked up, and the sister was like, What did he just say? I was like, I just can't believe what that guy just said to me. I was speechless.

Dr Maria Christodoulou 52:16

But you know, you're also right about how you've cultivated a capacity to sort of regulate which thoughts should be spoken out loud. You talk about the out- loud voice. And I think in one of your books, you describe yourself as I am she who never shouts. And that people always comment about how calm you are. So I'm wondering, what does it take to rein in that voice that's tempted to say a whole lot of things out loud that the adult in you knows shouldn't be said out loud?

Staying Calm Without Swallowing Rage

Dr Anne Biccard 52:43

Well, I think because when you start shouting, other people stop listening. And it also shows you've completely lost control of a situation. So as soon as you feel the need to shout, you have to like introspect for a moment and go, okay, I'm actually panicking. That's the reason that I'm shouting. And that's not gonna help a nyone. Let's talk about life on the farm and the multitude of rescue animals that are part of your life. Greyhounds, I can tell you, don't own a greyhound if you don't want to spend money at the vet. They are like V8 engines in balsa wood frames. They go too fast, they have no brakes,

Farm Life And Rescue Greyhounds

Dr Anne Biccard 53:22

and have no sense of caution. When they run, they run like crazed animals. And they run into things like trees and other dogs, and then they break their legs, and then you spend three years and half of your entire fortune trying to put plates in their legs. So they are very expensive, emotionally and financially expensive animals to own.

Dr Maria Christodoulou 53:50

How did it start? Why greyhounds?

Dr Anne Biccard 53:52

Well, initially it was pointers, actually. You know, pointers they are dogs like border collies that people think are nice to own, but then they realize when they actually own them that they are very high maintenance and that they run circles around your lawn and wear down all your grass and chew off your windscreen wipers, and generally are pestilent animals unless they work. So people get pointers and then they don't know what to do with them, so then they give them away or re-home them or try and find in another place for them. So it was initially pointers, and then I had a pointer called Brown Dog, who was quite famous in the first book. I don't know if you read about Brown Dog?

Dr Maria Christodoulou 54:34

I did read about Brown Dog. He became famous in the ER.

Dr Anne Biccard 54:38

Exactly. And somebody from Baragwanath was like, oh my goodness, it's a Brown Dog. And I was like, How do you know about Brown Dog? So it had been sort of passed from one doctor to another and used as a training tool that when somebody collapses on the ground, their eyes wide and their limbs paralysed, they may just be having a "brown dog" episode. Because she just used to collapse if you shouted Brown Dog. She would just fall over, her tongue would hang out, and her eyes would be open, and her legs would be paralysed. You could literally like lift her up like a dead tiger. So she had puppies, Brown Dog. So Brown Dog was the last of the pointer line, and then we kept some of the puppies, so they were the last pointer puppies. And then I don't know, we saw Jake at an SPCA or somewhere. He's the prime Snoopy, the one who initially broke his leg. And then everybody hears that you might be willing to take a greyhound. And then you look around and you have 16 greyhounds.

Dr Maria Christodoulou 55:35

Sixteen. Oh my word.

Dr Anne Biccard 55:37

Sixteen greyhounds. Now we only have nine.

Dr Maria Christodoulou 55:40

As though that's much less. Numbers are down, yeah, exactly. Gosh, that's a lot of work.

Dr Anne Biccard 55:46

They're lovely dogs.

Dr Maria Christodoulou 55:47

You also wrote about, is it Timon, the meerkat, and Merle, the crow? Timone.

Dr Anne Biccard 55:53

Yes.

Dr Maria Christodoulou 55:54

And at some point you resuscitated a monkey that was brought into an ER. I mean, clearly animals are an important part of your life.

Dr Anne Biccard 56:02

No, they are. I much prefer animals to humans mostly. I mean, I could never be a vet. If my dog has a broken leg, I have a much more visceral reaction than if a human has a broken limb. I'm like, oh, that must be sore, but it's not quite the same. And also because you can't explain to animals, you know. You can't explain to them that you're going to fix it or you're going to... You can't really tell them they need to calm down. I did tell a patient the other day, you need to calm down.

Dr Maria Christodoulou 56:27

I don't know if that works.

Dr Anne Biccard 56:28

She was not impressed, she was just making herself feel worse. I was like, stop breathing so much, you're going to make yourself feel weird. I'm like, stop doing that. You're having a panic attack. Calm down, stop breathing so much. And she's like, I can't move. I can't move. I'm like, you can't move because you're blowing off all your carbon dioxide, and so your pH is changing. So stop breathing so much. I wanted to put my hand over her face and say, stop it. You know that Bob Newhart video?

Dr Maria Christodoulou 56:57

I can't believe you know that video. It's such a funny video. Stop it or I'll bury you alive in a box.

Dr Anne Biccard 57:02

Exactly. What are you? Some kind of kook. Just stop it.

Dr Maria Christodoulou 57:09

Yeah. You also write about your hobbies and you play the piano, you play the cello. When and how did you learn to do all of that?

Dr Anne Biccard 57:18

So I had cello lessons. It was a thing I've always wanted to play. I just love the sound of the cello. It's actually the closest sound to the human voice. And it's just a beautiful instrument. So I had cello lessons, but then when we were robbed, whatever you want to call it. We weren't really robbed, but anyway. We didn't have anything of value. So when I had my cell phone stolen and got shot for the price of it, the guy ran into the house and knocked the cello over. It was on a stand. I don't know whether he intentionally broke it or I'm not really sure because I wasn't standing around. And the cello smashed, and then I never got it repaired for many, many years. Because it felt to me like some part of the music in my life was gone, in any case. So that was a long time. And then I started playing again. I found the guy who was selling a second-hand cello and I bought it and started playing again. So that was nice. And then I traded in the two pianos I had in the house for a new piano. But sadly, that piano had a broken frame, so it's been replaced. So I'm waiting for it to come back. The music is I just love music. I was just listening to Handel. It's lovely. The music is just... It just gives meaning to l ife.

Dr Maria Christodoulou 58:35

Yeah, I must say, when I was reading your books, all these stories about people who had come into the ER. And then the contrast between what was happening in the hospital and what patients were experiencing, and your capacity to navigate that space with a measure of equanimity, and then the contrast with the life you described on the farm. And it felt like almost like there were two different parts of you. I couldn't imagine the woman who was on the farm watching the sunrise or walking with her animals being this person that you were in the ER. They almost felt at odds with each other.

Dr Anne Biccard 59:15

They do, except they have the same background music. Under the surface, there's like a background music to your life. And that background music is the same. And I think mostly there's noise and chaos, but underneath that there's a connection.

Empathy Eye Contact And Control

Dr Anne Biccard 59:31

And I was thinking about what you were talking about, how to change the curriculum. And I thought after that, how do you teach people empathy? Because I don't think that people that get into medical school necessarily know what it's like to be poor or sick or disadvantaged in any way. So, how do you teach them empathy? And I would imagine that one of the first ways to teach people empathy is eye contact and acknowledging them in the consult. So to take that moment to ask a question to put you and the patient on the same side to connect with them. So even if you ask them who are you named after, or what nationaliy is your surname, or whatever, is a question to lead them into some kind of context with you. And then eye contact is so important, and you never learn that as doctors. You don't want to make eye contact with people because you have to guard your time and energy, because otherwise people just sap you dry. Once you let your guard down, you basically are... You lose control of the consult. And that's every doctor's worst nightmare. Well, not maybe every doctor, but most doctors. So it's very hard to learn empathy and still keep control of the situation. And to kind of listen to the person's like body cues and their facial expression and not be focused on having to perform the whole time. And in a way, that losing yourself in the consult is in a way really the only way to get to the bottom of what's really going on. Because if you yourself are standing separate from the consult, then you're not really in the moment, are you? Sometimes you need to just lose yourself in the moment of the intuition and stop trying to make a diagnosis and trying to be a particular thing, but just listen to some other cues.

Dr Maria Christodoulou 1:01:36

Yeah, it's interesting. I mean, I think the changing demographic of students in certainly South Africa's medical schools, not all of our students are coming from privileged backgrounds. And so I do think that there are students who have deep empathy and understanding of what it means to be poor or what it means to be hungry. But I think the other side of it that I've always been curious about is, is it that they don't have empathy and we need to teach it to medical students, or is it that the curriculum almost forces you to deny your empathy in some way? Nobody gets rewarded for being kind, compassionate, and empathetic. You do get rewarded for having all the answers. Exactly.

Dr Anne Biccard 1:02:16

And if anything, you're just a pushover. And so the kind of doctors that you work with, you end up just going, ah, they're like a soft touch, they'll take this admission just because they're nice people. Whereas some of the other people are like not nice people, and they go, I'm not taking the admission. And then you like, oh, but you still respect their intellect.

The Messy Reality Of Private Healthcare

Dr Maria Christodoulou 1:02:35

You wrote to me the other day that you feel that our training as doctors focuses on academic prowess. And this is the bit that I think is really key to some of the dilemma we find ourselves in in medical practice, and that it's about avoiding the messiness of the human condition.

Dr Anne Biccard 1:02:51

It is. I mean, nobody wants to be involved in that. They look into the future and they go, okay, this patient's going to be burdensome because now they're old and they live on their own, and maybe they have gastro, but now how am I going to get rid of them? Where are they going to go? Now their family's finally managed to get them into hospital. Now they're not going to want them to go back home where they live on their own. So now they're going to want to place the patient, and now I'm going to have to fill in thousands of forms, and the medical aid is not going to authorize anything, and it's just going to be a hassle. And it is true that one event happens, like the patient gets a bad gastro or they fall and break their hip, and then it's the fall that changes the patient's life. And that change of that life with step- down and ongoing medical problems, it's a hassle, and you don't get paid for it. And often the medical aids are intransigent in not paying for stuff. I mean, I had a chap who came in who was walking his dog at the nearby park, he was on Xarelto, a blood thinner, the dog pulled on the lead backwards, he fell over backwards, hit his head and he had a loss of consciousness. He comes in, he gets a scan because that's the protocol - first of all, because he's on Xarelto, and secondly, because he had loss of consciousness. His medical aid will not pay for that scan. So now he's a pensioner, he doesn't have money. I mean, I must have spent six hours writing motivations, speaking to the person at the medical aid. And I was like, you know, I'm not getting paid for this. And I can't speak sense to these people. I've asked to speak to the medical director, I've sent letters, I'm like, this is the protocol. You have to pay for the scan. It was a PMB, you have to pay for it. What else can I do? And now every time I'm on shift, I get a message from this guy. Please phone him back. The radiology department is suing him, he hasn't got any money. They've reported him to the credit control council. I'm like, this is actually not my problem. I just did the correct thing in terms of medical management. But now I'm sucked into this vortex of energy that there's a whole bunch of other factors that are going on that I have no control over. And I have to say at some point, I'm sorry, I actually can't help you. I can only write a letter of motivation and speak to the people there. You're going to have to make a plan. You know, it's your medical aid. I don't know what to say further. So I think that quite often physicians kind of look into the future and go, this patient is going to be so much hassle that I don't think I want to be involved in it. And I can kind of understand why people do that, because if you anticipate the amount of paperwork that's going to be involved, and quite often patients will say to me if we're doing a sedation or whatever, you know, what if I die? And I'll say, no, no, it's too much paperwork. And you know, it is just too much paperwork. I'm just not having you dying on my shift.

Dr Maria Christodoulou 1:05:38

If you could go back, if you could start again and be 18 making life choices, is there anything you would do differently?

Dr Anne Biccard 1:05:45

First of all, I would not like to be 18 again. Just to say, like most people would want to go back. I was not a happy person between 18 and 28. So I don't think I'd like those years again as myself. Obviously, if you go back and do something else entirely, then you could reconstruct your entire life. But probably I would go into some kind of IT robotics kind of thing. I think in terms of animation, and I would have loved to have been able to actualise that kind of thing. So I probably would go into that kind of thing. I mean, medicine, you know, often people they send people to job shadow, whatever, and you take them to the tea room, and every single doctor says, don't do medicine. And I'm like, why not? It's actually a good career. You have a job, it's meaningful. I mean, you don't earn money commensurate to the amount of responsibility you take, but it's not like you earn terribly. It's a good career. There's nothing wrong with it. It's a long road, for sure. Then if I had to be me at 18, I would have done medicine because that's what I wanted to do. But if I had to be someone else, which was also could be a nice option to be someone else, you know, somebody else entirely, I mean, then maybe I would choose to do something in IT robotics, some kind of way of constructing a different reality through... I don't know, I know nothing about IT. Some of the older doctors that I work with are always asking me to help them with the computer systems. And I'm like, listen, if you're asking me, you're at the bottom of the barrel because I know nothing about that. So if I'm trying to help you with your banking app or whatever, it's a very sad situation for you.

Dr Maria Christodoulou 1:07:21

What do you wish you had known when you first started working in an emergency

What Experience Teaches Young Doctors

Dr Maria Christodoulou 1:07:27

department? So, from the perspective of you today and all these years of working in emergency rooms, what would you say to your younger self on her first day in an ED?

Dr Anne Biccard 1:07:37

Listen to the patient. You know, we're so busy listening to other things, our kind of own internal voice, and just listen to the patient. I mean, it's interesting because when you were talking about what medical students need to learn, the things like you need to learn to give people bad news. I never learnt that at medical school. I never figured out that I'm standing there with my arms crossed. But now I'll see that in my colleagues. I'm like, your body posture is giving a particular message. You know, we never had feedback on any of that kind of thing. It's painful, actually. That feedback is painful, but you do have to learn it. And we never did anything like that at medical school, like how to speak to people, how to communicate. I heard a very funny thing, which I actually can't remember, but it was on one of our resus courses about all the different phrases for like a patient has died. And the guy is like, you have to tell the family the patient is dead, in those words. Don't use, he's passed, it's his time, or whatever. And he had like literally 20 examples of figures of speech that people use to kind of soften the blow. But then by the end of the feedback session, the family actually doesn't know if the patient's alive or not. You know, I'm afraid we've lost him, or whatever. And then they're like, but doctor, are they still alive? Okay, like all this counseling for the last 10 minutes has been in vain because they're waiting for the word, you know, is he alive or dead? And also that you need to not try and like we always get the family out of there if there's a resus. And now the current thinking is don't do that. Let the family stand there and see that you're actually doing something and that you're trying, and that they tried, and that you've done everything that you can. There's no shame in it. You don't have to chase the family out. We're not doing anything, we don't need to be discreet about it. The patient's heart is not beating, and we're doing CPR and we're doing this and that. And you should be well enough groomed as a team that people aren't screaming and shouting and throwing things around, and that you are saying to the family, look, we've been doing CPR for 15 minutes, there's no sign of any response. What kind of condition is the patient generally in? Are we going to continue with this? What would the patient's wishes be? And they get onto the page. They know what you're asking them if you let them into the room. You can't come out of the room 15 minutes down the line and say, um, sorry, is your mother like actually got a living will or is she an organ donor? That's not helpful.

COVID And The Feeling Of Powerlessness

Dr Maria Christodoulou 1:10:13

I'm mindful of time, and the one thing you and I haven't talked about, which you write about a lot, is COVID and the impact of COVID. In one of your books, you say that you didn't consider the possibility that the virus would poison your relationship with medicine and damage it so deeply. Is there anything in particular that you want to share about COVID and the impact that had on you?

Dr Anne Biccard 1:10:35

I think the thing with COVID was that we had absolutely no idea what was going on. And I think that that is very hard as a medical profession to get our heads around that. We had literally every day there was a different protocol. And actually, a number of times patients said to me, I don't think you guys know what you're doing. And I mean, I honestly said, we have no idea what we do. And every day we get a different directive from the Department of Health. We're trying to prepare ourselves. We have no idea of what's coming. We have no idea of what actually the pathology is. I still to this day don't understand the science behind COVID. I don't actually know what happened there. There's some kind of massive inflammatory cascade that kind of happened at about day 10 with definitely a genetic component to it. It was just like you're watching a ship sink, and there's absolutely nothing you can do to make a difference. In those however many years, I must have done 60 resusces on patients with COVID, and it was zero success. Zero. So you just had no control. You would just see the patients coming in, they were hypoxic, they had those shocking-looking chest x-rays, and they either made it or they didn't. And actually, there was nothing that we could do as the medical profession really to make it different. You could ventilate them, but you knew where you were heading. It was literally like watching the ship sink, and there was nothing you could do. The whole idea of emergency medicine is you're supposed to be able to do something different. You're supposed to be able to change the course of events by recognizing something early, by acting on it. You have a patient who comes with an MI, you get them to the cath lab, you open the vessel, they have a good outcome, and that's the reason that I carry on with the work. Because those kinds of saves from Grim make you feel like you're doing something. You're doing something meaningful, you're changing the course of events, you are an active component in a good outcome. But with COVID, there was nothing we could do. We did a few things wrong, like not letting the patients in, at least the families in. We should have let their families in to see them. We should have let them into the ICU and not separated people from their families and not have patients dying on their own with absolutely no whatever, but we were doing the best we could. We didn't know then what we know now. Now I would just say open the hospital doors, and if the family wants to come in, let them, you know, they're going to be exposed to COVID anyway. We were all exposed to it all the time. I mean, it was crazy times. Patients would die, they'd ring a bell, these people would arrive there with these big plastic things and wrap the patient in plastic with all this masking tape. They were like in this space suit, like you deal with Ebola. I mean, it was crazy. It was crazy. There were no post-mortems, we wouldn't let the family see the bodies. It was crazy. But at the time, we thought we were doing the best thing to contain the outbreak. So it was a hectic thing because we didn't know what we were doing. And we knew that there was going to be trouble, but we didn't know in what form it would take. And as I said, now I see some doctors who do transplants for people who have been waiting now for years for a lung transplant, and they say patients with COVID, their lungs are like concrete. Instead of being like a spongy elastic tissue, it is like a block of stone what they take out of that patient's chest to do a transplant. So what happened there? I don't know. They obviously got some massive inflammatory cascade that just obliterated their lung tissue. And definitely there were two kinds of COVID, the kind of neurological COVID and the respiratory COVID. And I mean, I definitely had the neurological one, it was the weirdest thing. My sense of taste just disappeared. I still don't have any sense of like no smell or taste at all. I can only smell if something's burning, then I can smell that. But the rest of the time, I mean, we had a sewage leak in the hospital. I mean, literally like wading around in boots in this sewage. Everybody's like retching and like fleeing from the casualty. And I'm like, I can't smell it. I'm totally unfazed by it. I just completely lost my sense of smell. Gone. From one day to another, like your nose has been cut off from your brain. But I didn't have any respiratory symptoms.

Dr Maria Christodoulou 1:14:52

And you stayed in medical practice.

Dr Anne Biccard 1:14:54

Well, I can tell you, if I had to see COVID coming around again, I would flee. It was crazy.

Dr Maria Christodoulou 1:15:00

Would you?

Dr Anne Biccard 1:15:01

I don't know. I don't know. You know it's that stubbornness hey. I'm like, you think you've got me. Every night I'd stand here and look at the sunset and go, I'm still alive, Mr. COVID. And you know that moment when you just want to give up and go, okay, you got me. And then you think, no, but you actually don't. I'm still going to come to work tomorrow. So there.

Dr Maria Christodoulou 1:15:24

Who are you talking to when you have that conversation?

Dr Anne Biccard 1:15:27

No, I don't know. I have no idea. I was just thinking that myself, because mostly I'm on the same side as the universe, certainly when it comes to like music and things. I'm like, thank you, universe, this is really good. So I'm not really sure where that comes from, but I was so there. And I thought to, you know, could I be talking to my mother? I was like, no, no. Because I wouldn't have said, so there, to my mother because that wouldn't have ended well for me. I would never have gone down that road. So yeah, COVID was a crazy time.

Fear And Silence In State Healthcare

Dr Maria Christodoulou 1:15:56

Is there anything I haven't asked you about, Anne, that you would like to share?

Dr Anne Biccard 1:15:59

I think you've asked me about everything.

Dr Maria Christodoulou 1:16:01

We haven't talked about one of the concerns you mentioned the other day, and we did agree that it might be beyond the scope of the podcast. But you said that your major concern is the future of healthcare in South Africa and the rapid decline in government health service in the past few years. If we allowed that out- loud voice to say exactly what it wanted to say, what might you say about all of that?

Dr Anne Biccard 1:16:25

I think that what is not right is that the people that I think that I know in government, or that I know, but I think that I know what they think, are not allowed to say what they think. And I think that is the start of a very bad situation for everyone. If you can't speak out about the organisation in which you work, and you are scared to say something because you'll lose your job, or worse, that's not a good thing. And it doesn't bode well for the future of where we're going, because you need to feel safe enough to speak, to have a voice, and to say what you think is wrong and to say what you think could be done to fix it. And I think that that overriding fear... So when I was a houseman, I was interviewed on Carte Blanche about community service, and I said what I thought, and that was that our year was never consulted about community service. Basically, at the end, when we were housemen, they suddenly said, you are going to do an extra year. And I said, That was not the agreement. We didn't come into medicine knowing that. We were never consulted about that. And now, as housemen, we are working literally 90 hours a week, and I'm not prepared to do that for another year. So if you want us to do community service, we are working 40 hours a week. And maybe if we choose to do overtime, there was no choice for us. You had to do overtime. That was your job. Your house job was a nightmare year, and that was how it was. And you knew that. You prepared for that, you knew it was going to be the worst year of your life, and you just had to get on with it. But now, halfway through the year, they say we're going to make it two years. And I was like, I'm sorry, but anyway, I was the houseman representative, and I went to a meeting with Zuma and blah, blah, blah. But I said what I thought, and I never feared for my job or for my life for saying what I thought. They may not have agreed with me, and I can tell you, Nkosazana Zuma was an incredibly convincing woman and very charismatic, but I felt personally that I'd been wronged by that. That I had paid my fees, I'd worked very hard for the dean of the university to say, yes, we agree that you guys need an extra year of training. What are we going to get trained doing what? Going to some peripheral hospital where there's no supervision? That's not training, that's free labour. And so I was very outspoken about that. And we, as much as you can try and herd doctors together, which is just about impossible, it's like herding cats. But we agreed as housemen that if we had to do community service, we were working maybe 56 hours a week, but we were not working more than that, and actually we were only compelled to work 40 hours. And if we didn't want to work overtime, we didn't have to. And of course, that would have brought healthcare to its knees because housemen did everything there. There was no community service. There were registrars, but they were in their particular thing, and the consultants didn't come in to actually work on the floor. They would come in for ward rounds and for theatre, obviously, or whatever. But at the end of the day, the housemen were the people who were running show. And so, what I'm trying to say is that we could speak out and say what we thought. Whereas now I feel in government they can't speak out and say what's actually going on. So half of the people there have left, they won't pay over time, they're not making new posts. So people are leaving in droves, and there just isn't the personnel, there isn't manpower. But the really frightening thing is nobody's talking. Nobody's saying what are we going to do about the situation? You know, it's not my concern. I don't work in government and I have no political influence, and actually, if you had to ask me what I'd do again, I'd become a politician, so I could change things. Of course, if I became a politician, I'd have to be a different person and not be so out spoken. But I've sort of realised there's a parallel universe of people who actually make a difference, and those people are in politics. And you can't change horse mid-race. So it's too late to do that. But actually, they are the people with influence. If anybody's going to change anything, it's people who are high up in the Department of Health. It's not me on the ground shouting odds. That's a ladder that I haven't climbed, and I'm on a different ladder. But of course, I couldn't be a politician.

Dr Maria Christodoulou 1:20:55

What makes you say that?

Dr Anne Biccard 1:20:56

Too honest. No, I mean, look, I think you have to have a particular agenda to be a politician. And I'm not sort of focused enough on what I would have to say to get the support of people. I just say what I think, not what I think other people want me to say.

Dr Maria Christodoulou 1:21:13

Which might be a good quality for a politician, but yes.

Dr Anne Biccard 1:21:16

Yeah, but you'd never get the vote because people don't want to hear what the reality is. They don't want to hear what actually is going on, they want to hear what they want to hear. So, I mean, it's frustrating from the outside because I feel that people in South Africa, there are the resources to have good healthcare. There's no reason why we shouldn't have good healthcare. And it's not impossible to provide

Kindness Gratitude And Closing Reflections

Dr Anne Biccard 1:21:39

it. It's just wrong.

Dr Maria Christodoulou 1:21:41

If we could fast forward time and, I don't know, maybe we're both in our 90s sitting on a stoep somewhere looking at the sunrise, and I asked you what you wanted to be remembered for, what would you say?

Dr Anne Biccard 1:21:55

Maybe playing Rachmaninoff's second. Although I do really want to do that.

Dr Maria Christodoulou 1:22:00

I love that.

Dr Anne Biccard 1:22:01

Such a beautiful piece of music, you can just feel like that Russian..... Um, what would I want to be remembered for? I suppose kindness. I think that kindness is vastly underrated. You don't realise how important it is just to be thoughtful about other people's perspectives. Life is different for everyone. It's like that story I wrote in the book about the person who phoned the casualty because they thought their cat was dead. I don't know which book that was in. And I was like, well, this is what you must do. And then I thought, you know, actually the person just needs someone to be there with them. You don't need to necessarily do anything. You just need to be there and actually just be present and not always be trying to fix something, but just be kind in the moment. Well, I try and be sometimes my outright voice overwhelms me, and a little unkindness might escape me. Because I also have a very sharp tongue, which I can't help. I inherited it from my mother. I do try very hard not to say things that my mother would say. I was teaching a child to ride a horse a little while ago, and she had a temper tantrum, and she said to me, You're hurting my feelings. The first thing that I said, it was just my mother. It just came up out of my mouth. I was like, You want to have feelings, they're going to get hurt. And I thought, goodness, where did that come from? It's like you put on a jersey and your mother's hand comes out the sleeve, and you're like, oh.

Dr Maria Christodoulou 1:23:37

Yeah, my siblings and I often sit and joke, even with my mother, about all the sayings we've internalised from her from childhood. All the different things that she would say.

Dr Anne Biccard 1:23:47

Yes. No, my mother was a very strict person. I remember having a discussion with her that she wanted me to tidy my cupboard. And I was like, no, Mom, there's been a new spider discovered in South Africa. I read about it. You know, I was obsessed with medical books. I read about. It's called a violin spider. And there might be one in my cupboard. And I just remember she stared at me and said to me, I don't care if there's an entire orchestra of spiders in your cupboard. You'd better tidy it. And that was my mother. Not interested in my little violin spider or the entire orchestra of spiders. I just better get on with it.

Dr Maria Christodoulou 1:24:30

Yeah. Well, it sounds like that 'just get on with it' personality trait has stood you in good stead in your life.

Dr Anne Biccard 1:24:38

Yeah, it has. And I have to say that for all the conflict with my mother, she taught me a lot of resilience. Which I think is something that is also vastly underrated.

Dr Maria Christodoulou 1:24:49

Yeah. Gosh, this has been a very interesting conversation, and we've gone down many different rabbit holes. Is there anything you'd like to say in closing?

Dr Anne Biccard 1:25:00

Just that it's raining. It's very beautiful on the farm. There's like a lovely huge cloud rolling over the hill. And the plants are all saying thank you for the lovely rain. It's like a gift rain. You don't have to actually try, it just comes along. You don't have to actually like put the input. There are very few things in life like that, that don't cost anything. I suppose, you know, storms cost you a lot. Lightning costs you a lot, but just a gentle soft rain is a gift. Actually, one thing I would like to say in closing is that we should be thankful every single day of our life for our good health. Every day that goes past, you see patients in the ED and you think, wow, I'm so lucky I'm not dealing with that terrible diagnosis, that terrible pain, or that bereavement, or that whatever. Like every day that goes past, we should say thank you to the universe, for what we have, not what we don't have.

Dr Maria Christodoulou 1:25:58

Yeah, I'm with you on that. Absolutely.

Dr Anne Biccard 1:26:00

Sound like I'm a zealot. What do you call it? Like a religious zealot.

Dr Maria Christodoulou 1:26:05

Well, you know, I think that there is something about that confrontation with mortality that wakes you up to what matters most and how fortunate we are to be in good health, walking around, living our lives, going about day-to-day things, actually.

Dr Anne Biccard 1:26:19

You don't appreciate it until you don't have it. And it's so ironic, but it's so true. You just take it for granted until you don't have it. And then you look back and you go, I can't believe I wasted all that time that I had such good health and I never appreciated it. And then when you don't have it, you realise you have nothing if you don't have your health. You can have all the money in the world, you can have everything. There's no substitute for not having pain. I had a friend who died a few years ago but I looked after him for a good few years before died. I mean he would say you could go and buy a pair of shoes and says it's a five-year guarantee. And it's like, doesn't matter to me. I'm not going to be here in five years. And you think, wow. That's quite important.

Dr Maria Christodoulou 1:27:03

Thank you, Anne. Thank you for making the time, for sharing your story, for the amazing books that you've written that really highlight in a way that nothing else has. Certainly for me, I don't have much ER experience, but I felt like I was right there in the room with you going through all of those things. And there were times when I laughed, and times when I cried, and times when I was really touched by the vulnerability of being human. Thank you. Keep writing is what I'd like to leave you with.

Dr Anne Biccard 1:27:34

I've got nothing more to say now. What am I going to do?

Dr Maria Christodoulou 1:27:37

I suspect you might find you have lots more to say going forward.

Dr Anne Biccard 1:27:41

You never know. I think the next thing I'll write is a cookbook, so we'll see.

Dr Maria Christodoulou 1:27:45

Oh. Okay.

Dr Anne Biccard 1:27:49

Not a chef. Thank you so much. It was such a nice interview. Really, very nice. It's made me think about a lot of things. I'm going to have to come back to you with a few answers of questions if I had to do things again and what would I be remembered for. Jeepers. I don't know.

Dr Maria Christodoulou 1:28:03

Yeah, well, thank you for entertaining my questions. I really appreciate it. I'm Dr. Maria Christodoulou, and you've been listening to the Awakening Doctor Podcast. If you enjoyed this conversation, please share it with your friends, follow Awakening Doctor on Instagram, Facebook, and Spotify, and go to Apple Podcasts to subscribe, rate, and give us a good review. Thank you so much for listening.