Growing Into Medicine (12 page)

I had sampled the world of medicine outside hospital even before we moved to Portsmouth. After my first year in hospital I was free to be let loose on the public. I took a job for two weeks as a locum in Ackworth, a village three miles from Pontefract. We knew the doctors to be conscientious, although in our view from hospital somewhat over-anxious. The senior partner went on holiday, leaving his junior to keep an eye on me. Faced with the undifferentiated illnesses of general practice, most of them minor but with an occasional emergency not to be missed, I was completely lost. I
hardly knew how to write a prescription, having used nothing but the bed-end charts on the wards, where my drugs were checked by a competent ward sister and again by the hospital pharmacist.

This was the moment when I started to ape my mother by wearing a coat and skirt, perhaps in the hope of annexing some of her confidence. The small BNF lived in my pocket, as it had done in my white coat in hospital. It was my Bible. I did not have the confidence to refer to it in public, as I learned to do later, but I consulted it while the patient dressed behind the curtain, on hasty trips outside the consulting room or in the car between visits. I soon realised that patients were not happy if I challenged their own doctor’s advice. Wherever possible I would repeat what the regular doctor had already prescribed.

One woman stays in my memory. She was a hotel proprietor, on her feet all day. She asked for a visit because her foot was painful. Arriving at the large building I found she had slight swelling and tenderness over one of the long bones of her foot. I thought it was probably a strain but it could have been a ‘march fracture’, a spontaneous break due to physical stress on the foot. Coming from hospital, where we tried not to take unnecessary X-rays, and knowing the treatment would be the same, I strapped the foot and told her to rest – I don’t remember discussing the difficulties of doing so when she had a hotel to run. When her own doctor came back he ordered an X-ray and it did indeed show a hairline crack. The patient was furious and considered me negligent despite the fact that the treatment was not changed.

The same problem could arise with a simple cracked rib. In hospital, provided we were sure the lung was undamaged, we were encouraged not to ask for an X-ray. In those days we applied tight strapping to the chest. (This is no longer advised because of the fear of infection in the less mobile lung.) Doing the simple task with care was one of the few occasions when one could provide immediate relief from discomfort. Another was syringing ears. A modicum of skill was needed in those days when we used a metal syringe: the appropriate pressure had to be applied in the right direction. Since
then the ear irrigator has been developed. It allows electronic adjustment of pressure and the task has been delegated to nurses.

I now realise that patients need to know what has happened to their bodies, especially if a bone is broken, even if the knowledge does not affect treatment. A sprain is just a sprain, but a broken bone elicits more sympathy from family and friends and justifies a longer convalescence, even though a bad sprain can be more troublesome than a clean break.

My trainer in Portsmouth, Dr Burnham-Slipper, was a well-established and conscientious general practitioner. At that time there was little supervision of trainers. Some were exploitative, benefiting from the fee they were paid but using the trainee as an extra pair of hands to help shift the considerable burden of work. I was lucky to have found a man who gave freely of his time and took his training role seriously. For the first time since I had obtained my degree, I felt adequately supported. For at least three weeks I sat in on his surgeries and went with him on home visits. When I started to consult alone he was always in the next room, available to give advice if I was in any doubt about a diagnosis or management. When I started home visiting by myself, we met over lunch and at the end of the day to discuss cases.

The routine in Portsmouth was very similar to the one I had observed as a child. In both practices long surgeries were held twice a day, on a first-come first-served basis, the queue of patients overflowing the small waiting rooms. In Chippenham they had perched on the walls at the top of the surgery path which ran along the side of Lowden Hill. In Portsmouth twenty years later there was less room for the patients to wait and they would spill out through the small front garden onto the road.

All GPs in those days made many house calls, in response to requests for new visits, to follow up cases and to a list of regular elderly patients. However, there was no local hospital run by the GPs in Portsmouth as there was in Chippenham, where my father did a ward round each day, with an opportunity to drink coffee and talk with other doctors in Matron’s sitting room.

Under the NHS, introduced in 1948, hospital medicine was advancing and becoming more organised. Because the system I was now working in was so similar to the one I had known as a child, I was not aware that general practice was falling behind, becoming the poor relation. Doctors organised their own practices, perhaps with the help of a wife or secretary. Partnerships were small, usually two or three doctors often working in different premises. Nursing and midwifery services were separate. Individual doctors and nurses might try to work closely, but the employment of ancillary staff within the practice was still a long way off. Above all, this was a patient-driven service, the doctor responding to immediate demands. Preventive medicine was limited to the vaccination and inoculation of infants, usually carried out at clinics run by the medical officer of health and his staff.

It is now twenty years since I did any work in general practice. The changes have been profound. My son-in-law Simon, who practises in Swindon, worries about the efficiency of his practice manager, reaching his targets for screening and health promotion and his work in a deanery where he oversees the trainees and trainers. With cars so widespread most patients can drive or get a lift to the surgery so he makes far fewer home visits. He often sends patients with an acute illness directly to the hospital where the range of useful interventions has expanded beyond anything my parents could have imagined.

One of the most dramatic changes is in the treatment of patients who suffer a stroke. My father had several partially paralysed patients on his routine visiting list. One lady limped about her house with a useless hand and impaired speech. I was embarrassed by her handicap but intrigued by her white cockatoo with a yellow crest that shrieked ‘go away’ and ‘lovely boy’ when we visited. She would let it fly loose and cuddle it, allowing me to stroke its back with one finger. When she first suffered her stroke she had been nursed at the hospital. But her calamity had not been considered an acute emergency for there had been no immediate treatment – patients either died or lived with varying degrees of disability. In recent years,
specialist stroke services have been set up in many places. If the patient can be seen, scanned and a treatment regime started within two hours the outcome can be significantly improved.

The definition of a general practitioner that I was trained to fill was ‘A doctor to the individual, his family and a practice population’. I have always thought that the roles were not totally compatible. The conflict of interests has become more severe since the rise in patient expectations, the emphasis on preventive medicine and on financial considerations, made so much more acute by the challenge of scientific advances. But the individual patient is still preoccupied by the immediate symptom or anxiety. Health education and routine screening can feel irrelevant at that moment, and the focus of the doctor’s concern may be deflected. I wonder how much the pressures on the doctor to fill many different roles underlie the discontent that I hear from so many elderly friends, who feel their doctor has no time to listen or empathise. When my father visited his chronically ill patients he had little BUT time to offer. Despite the major organisational changes, appointment systems, computerised records and teamwork, the heart of primary care remains what it has always been, a meeting between a troubled patient and a doctor wanting to help.

After my year as a trainee I stayed on in the practice as an assistant. Ralph was now working with adult prisoners for the first time. Some of these were serving life sentences for murder, and his contact with them stimulated an interest that began to take the place of his concern for young people and was to last him the rest of his working life. He worked more civilised hours so we could spend most of our evenings together. There was no room for his archery in our cramped quarters but he joined a judo club. Although I was becoming more tolerant of his strange hobbies, when he filled our bedroom with weight-lifting equipment I was irritated. We still went to western films but I was getting used to the guns. Our relationship was strengthened by a couple of very enjoyable holidays driving round France and Italy. However, my personal concern was that I did not seem to be getting pregnant.

Both my parents had stressed the disaster of getting pregnant before I was qualified, but as soon as I had those precious initials after my name I had stopped using my contraceptive diaphragm. After three years I saw a consultant in Bath who gave me temperature charts to try and discover if I was ovulating, a passion-killing device of the worst sort. After a few months it showed no rise in the middle of the cycle. I was not producing egg cells. It was senseless to feel we had to perform to order. I took the various ineffectual hormones available at that time and tried to concentrate on my work.

Two patients stand out in my memory. The first was a woman in her thirties, desperately ill in the last stages of septicaemia and kidney failure. By the time she plucked up the courage to send for me she had passed no urine for two days. I called the ambulance and sat on her bed while she confessed that she had been to an abortionist, a local woman who ‘helped’ women in trouble. She died three days later. The unnecessary death of that patient, caused entirely by the laws and social mores of the times, has haunted me to this day. The year was 1956 and I will never forget the desperate plight of so many women before the abortion act was passed eleven years later. If one had money, or a friend with the right connections, a gynaecologist might be persuaded to perform a D&C on some pretext such as irregular periods. If one had no such advantages the back street abortionist with her knitting needle or other unsterilised implement was the only answer. Sex education was totally inadequate and the pill was still a dream in the mind of a few research scientists.

My father told me of being called to see a young girl who had delivered a baby into the toilet, having had no idea that she was pregnant. Even in the 1980s, in a suburb of Bristol, I was confronted in a family planning clinic by a twenty-year-old who came with her boyfriend. They both denied any knowledge of her 36-week pregnancy, having convinced themselves that she had been overeating.

The other patient in Portsmouth I remember with great clarity
was a woman who, on several occasions, developed acute breathlessness at night due to the failure of the right side of her heart. I treated her with slow, intravenous Aminophylline, a technique I had perfected with my asthma patients in hospital. (This treatment is not used now because of occasional ill effects.) After a time the response was a relief of symptoms that made it possible for the patient, previously standing at the window gasping for air, to return in comfort to her bed. Anxiety made the symptoms worse so I always stayed for at least half an hour. Clothed in the aura of doctor and with my nerves held firmly in check, I found it deeply satisfying to be able to provide the necessary calm.

By this time the local doctors had organised a rota system that left one of us on duty for the patients of three practices at the weekends. There could be fifteen or even twenty new calls on each of the days. We did not employ a driver as some larger groups did later. Luckily by this time I knew the geography of the town fairly well – but not well enough. One Saturday afternoon I parked outside the house of a child with earache. To my horror, when I came out there was a mass of people streaming past the car. I had not realised that the road led from the football ground. The river of humanity went on and on, and I had several calls waiting. I got in and tried to move slowly past the oncoming torrent, only to be met by catcalls of abuse and beating on the windows. I had no Doctor sign on the car and there was not a policeman in sight to help me. In the end I edged backwards, going with the tide. I have seldom been more frightened by the strange organism that is a large body of men, all individuality lost. The composite life form is governed by different and terrifying rules. Not one man lifted a finger to help, each egging the others on in more and more insulting slurs on my sanity and my female driving.

At the end of my second year with Dr Burnham-Slipper, Ralph heard he was to be sent to the London School of Economics (LSE) for a year. Later we discovered the plan was to appoint him to an open borstal south of Birmingham, between Redditch and Bromsgrove, called Hewell Grange. The future governor was to be Alan
Roberton who was studying at the Tavistock Clinic while Ralph was at the LSE. The idea was for them to learn some psychological and social theory and then devise new schemes of rehabilitation. Alan and his wife Dilla were to become our closest friends.

Ralph was not naturally gregarious; I can understand him best if I think of him as a closet hermit. A few people could turn a key and get him talking. At those times he would hold the room spellbound. But he could not engage in the normal give and take of social discourse. He would reply to questions about his life and family but would never ask a question in return. I should have tackled him about it. As always I did not, but tried to show by example how such interchanges took place, an exercise that often embarrassed him. I realise now that what appeared to be lack of interest was a sensitive attempt to protect people in the way he would have wanted to be protected. His need for personal privacy was acute. The Japanese idea that to give a present was to put the other person in your debt appealed to him. He liked the symbolic, anonymous scarf that did the rounds with no personal attachment. His restraint provided a foil to my need to ask questions, to listen, to offer sympathy, to ‘wag my tail at everything’ as my daughter Helen once put it. I wish I had understood the workings of this dynamic earlier in our life together. At the time I was confused, for his silences made him appear cold in public, yet I knew that he was in reality one of the warmest-hearted people I had ever met.