Eating the elephant – together, one bite at a time

This is a transcript of a speech given to the Australian Medical Association’s National Conference by Jessica Yang, President of the Australian Medical Students’ Association, in Brisbane on 26 May 2019. Watch the recording of the speech here.

I AM thankful for the privilege to study medicine and to be representing 17 000 of Australia’s future doctors. My name is Jessica and I am studying at the Western Sydney University School of Medicine.

I am thankful for my identity and my upbringing. I come from a diverse background; I was born in a helicopter flying from a rural island off the coast of Hong Kong, so my parents insist I was born to soar to great heights. My parents are from China but they grew up in Japan. When I was 10 months old, my family moved to Australia where I now live in western Sydney.

Mine is a dynamic, cultural experience that many Aussies can relate to, and are proud of. Maybe not the helicopter part. But the bridge between my ethnicity and my nationality was one that I struggled with. When seeking support for my presidential bid, I had specifically been told that my age, gender and most pertinently, my race would make me an unattractive candidate. “You don’t sound Asian,” a stakeholder told me, “so you’ve got that going for you”.

When I was elected at the Australian Medical Students’ Association’s (AMSA) Second Council in 2018, I was informed that I was the first non-white AMSA President.

My first reaction was one of disbelief. I am surrounded every day by my colleagues from all backgrounds; when you consider the diverse makeup of the medical workforce, whom society looks to as leaders, how can our leadership not reflect this?

A friend of mine who is of Indian background told me: “You should be proud. Because of your visibility, more people who may not fit the mould of a conventional leader will be encouraged to put their hat in the ring”.

I responded to this with indignation and fear. Why was it now up to me to lead a crusade of diversity within medical student leadership?

As you’ve probably gathered, these two reactions were incongruent: I was simultaneously complaining about the current state of representation but was wary to take ownership of the opportunity to make change.

I thought back to an interaction in 2016 I had with the now Australian Medical Association (AMA) (NSW) President, Dr Kean-Seng Lim. He told me: “There needs to be more people like you at the table. Make sure you stick around”.

Remembering this, I realised that it’s not about me. It is about my 17 000 peers who have given me the privilege to speak on their behalf. Many people in this room have the same privilege to represent their peers and I implore you to use this opportunity.

Use this experience to look out for those who do not have the same opportunities to speak up or create change. Use your seat at the table, use your visibility to lift others up, so they can be visible too.

It would be remiss of me not to mention Dr Yumiko Kadota when discussing non-conventional medical leadership. She published her personal story on her blog “The ugly side of becoming a surgeon”, where her experiences as an unaccredited registrar working 180 hours on call shocked the general public.

Unfortunately, for many of you in this room, and for those around me at medical school, this story of burnout and a lack of systemic support is not one that shocks us. It is all too familiar.

I recall my own experience as a student last year, which required a reasonable 35 hours per week of clinical contact. Then add 20 hours of recommended study, 20 hours of part-time weekend work to pay my rent, plus a 2-hour daily commute; any remaining time was spent simply surviving. This does not hold a candle to Dr Kadota’s experience, but it does makes me worry about what my future holds.

I went to the only local GP available after hours. I was convinced I had developed narcolepsy, as I frequently found myself on the verge of falling asleep throughout the day, most worryingly, behind the wheel. Perhaps I did have a temporary bout of stress-induced narcolepsy. Or, perhaps I didn’t want to admit I was burning out.

If this is the environment in which we start our journey and form our habits in medicine, what happens when we have the responsibility of patient safety on our shoulders? We work harder and longer and become more tired. We make mistakes.

Considering these experiences makes me think more broadly of the current state of medical education and training. High distinctions in exams, getting multiple degrees, “CV buffing” – these things certainly require talent, and look good on paper, but are we becoming better doctors in the process? Nobel Prize-winning economist, Michael Spence, observed the phenomenon where people pursued achievements to signal their worth, rather than to improve their skills.

Medical students are watching, and we’re worried. We see our mentors, who are vastly more qualified than us, fighting unprecedented competition for specialty training. We watch our recently graduated colleagues, who are pursuing a PhD for no other reason than to improve their chances of getting into training.

We hear stories of extracurricular courses and pre-training exams, which contribute to a very expensive curriculum vitae, just to keep up with shifting college goalposts. We think to ourselves “how am I ever going to get there?” Know that we are watching and listening to you, and we see that you are under pressure.

This pressure is filtering down into medical school. I was recently at an orientation week and a group of half a dozen first-year students approached the AMSA stall. They were asking about how to get involved. Great! I thought. I asked them why they were interested in joining AMSA.

“Honestly Jess, because extracurriculars look good on a CV.” This was their third day being a medical student; for some of them, it may have been their third day of university. These students had not stepped foot in a hospital and were already thinking about how to outdo their peers in 10 years’ time.

At last year’s AMA National Conference, a motion was passed to credit postgraduate clinical experience more heavily in specialty college applications, rather than the current focus on academia. I applaud this preventative step in addressing an increasingly competitive climate. It reinforces the idea that we should be working with each other for our patients and their safety, instead of adding lines to our CV, which do not drive our passions or improve our clinical ability.

Recently, I spoke at an event before a plenary by an incredibly impressive and well regarded doctor. As happens with many conferences, my talk was pushed back and subsequently so was his. He expressed his annoyance by telling the audience that I “should not have spoken before him” and then telling the event staff that I was a “naughty girl” and what I had to say was “irrelevant”.

I was humiliated. I felt belittled in my capacity as a leader and belittled because of my gender. This is the type of insidious behaviour that is perpetuating a toxic undercurrent of medicine. Many of us shrug it off, but I am asking you to call it out as my peers did for me at the time. While I am uncomfortable recounting this, as someone in a position of power I have a duty to do so, and so do you. We should empower those who are belittled and disregarded as unimportant because that is how we will create change.

When we express dissatisfaction with the status quo, medical students are told “it is your generation that will lead the change; just hang on until the old ones leave”. Please, stop telling us this. This idea of generational change only serves to isolate you from us. And we should be working together, now more than ever.

We cannot wait for change that may never come. We ourselves cannot change if we continue to advance into a system that disengages us and makes us cynical.

This conversation is not new to anyone [reading this article]. We have heard these calls to action [before], and even over the years from my predecessors. I would urge you to reflect on your time in medicine: what made your life better and what challenged you? What was the worst thing that happened to you as a student or junior doctor, and how can you stop it from happening to someone else?

The medical profession can do amazing things when they stand together for a common cause. Last month, AMSA was accepted as a stakeholder at the United Nations High-Level Meeting on Universal Health Cover. This incredible opportunity for international advocacy was only made possible by the tireless work done by hundreds of medical students who volunteer their time for AMSA and for our community as a whole. They juggle medical school and these demanding roles to improve the system for those who come after us.

The video played at the start of my address showcased the ability of passionate medical students to make change. In January, AMSA publicly supported pill testing trials and improvements to harm minimisation initiatives. In February, AMSA implored parliamentary support for the Medevac Bill. In March, AMSA rallied to demand action on climate change and its effects on health. On each of these issues, we stood beside the AMA and together, our voices were collectively amplified.

These are the issues that your future members want to see you fighting for and need your support on. I am thankful to AMA Federal President Dr Tony Bartone for being so supportive of our advocacy efforts and for actively welcoming me to the leadership table.

I have touched on a lot of different issues today which all come back to a fundamental need to change the status quo. These issues may seem insurmountable, but I ask you to consider the old adage: how do you eat an elephant?

One bite at a time.

It takes hard work to lift up your juniors, your medical students, and those without a voice, and to take them along with you on the ride. But it only starts with small acts of kindness: tell people to stick around, call out offensive behaviour, and take care of each other. Thank you.

Jessica Yang is the President of the Australian Medical Students’ Association, the peak representative body for Australia’s 17 000 medical students. She is a medical student at Western Sydney University. She can be found on Twitter at @YourAMSA and @JessHYang.

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.