Writers’ Traits

Writers’ Traits

I thought maybe the time had come to share my observations on characteristics that maybe let some writers down.

First, there is the obsessive type, the one who believes that every sentence should be word-perfect.  Well, strictly speaking, I suppose it should be sentence-perfect because word-perfect refers only to one word when, of course, a sentence has several words.  That is unless the sentence consists of only one word; in that case, by the way, the sentence would not only be sentence-perfect but also word-perfect because, to stress the rationale, the word and the sentence are the same.  The obsessive type can ponder for hours whether the grammar is right or, to be more accurate, correct.  I say that because the word “right” can also mean a direction.  It can also mean that which is morally right or an entitlement but then the word is a noun and not an adjective.  The obsessive types, poor people, become hopelessly lost in detail. 

Secondly, there is the flamboyant, the one who chooses, instils and develops words, phrases and sentences that transcend the reasonable, the ever-understanding and receptive mind of its reader into an ethereal world of superlative and distorted exaggeration, extending into fathoms of emotional depth and the stratosphere of heightened sensation that penetrates, indeed incises, the innermost core of a passive soul, transforming its recipient into an agitated, hypomanic, virtually destroyed representation of the essence of humanity.

Next is the depressive. Pure gloom. Isolated blackness.  Short sentences. Few words.  Hardly able even to finish a..

Finally is the smug.  What can I say?  Not much, except that I am proud never to have been afflicted with that trait.  Or any of the others, for that matter.

Teddy Bear’s Triumph Chapter 8 Post 1

Chapter 8 Post 1

One day, I was called to the medical ward by Dr. Hickens, a consultant physician, to see a middle-aged lady who had had episodes of loss of vision with mild headache.  After the usual introductions, I asked her about her attacks.

“The vision in my right eye goes suddenly.  My husband says it’s a blackout.”

“Well, in one sense, I suppose it is, but ….”

“So you agree with him then?”

“Well, the term blackout can cover a multitude of problems.   Certainly, it sounds as if your vision blacks out.”

“My obstetrician says my vision is fine.”

“Your obstetrician?”

“The man who checked my eyes.”

“Oh, your optician, yes I see.”

“My doctor says its My Grain” she said, with equal stress on the “My” and “Grain” and a staccato-like separation between the two words.

“Migraine, yes possibly.”

After learning of several more diagnoses volunteered to Mrs. Johnson by members of various professions and the lay public, I was able to pin her down long enough to be able to extract some relevant information.

“Are there any conditions that run in your family?” I asked.

“Well, my father had trouble with his preposterous gland.  He couldn’t pass water.”

“Prostate gland, yes.”

“Yes, prostrate gland.”

“And my cousin had celeriac disease.  He couldn’t eat wheat and had to have a glutinous free diet.”

“Thank you.  Coeliac disease treated with a gluten-free diet.  Yes. Anything else?”

“My uncle had a problem with his gall bladder.  He couldn’t pass water either.”

“Sorry, Mrs. Johnson,” I said, “there is the bladder, sometimes called the urinary bladder, which we use to pass water.  The gall bladder is different; it lies near the stomach.  It sounds as if the problem was with his ordinary or urinary bladder.”

“Well, he also had indigestion.”

“Anything else?”

“My mother had a gastric stomach.”

After thirty to forty minutes, I felt like a United Nations linguist carrying out translations of speeches in real time but had gleaned enough to conclude what was wrong with her.  I explained:

“The problem is that, from time to time, the blood supply to your eye becomes blocked.  Without its blood supply, the eye cannot function so you lose your vision.  However, after a short time, the blockage opens up; the blood supply returns to your eye and your vision comes back.”

“I think that’s what Dr. Hickens thought.  He said it might be a transit anaemic attack.”

“It’s actually called a transient ischaemic attack,” I said, “transient meaning temporary and ischaemic loss of blood supply.  So it’s an attack consisting of a temporary loss of blood supply.”

“Why am I having transit anaemic attacks?” she asked.

“Well, we need to find out.  We will have to do some tests to look at the circulation.”

“Ah, circular problems run in the family too.  My aunt had vigorous veins.”

“Well, varicose veins are actually a bit different.”

“So it’s not My Grain?”

“Well, it could be migraine but I think it is important to make sure that there isn’t a problem with your arteries.”

“So the tests will look at my hearties?”

“Yes.”

Varicose veins are the result of an improper selection of grandparents.   William Osler

We transferred her to Sheffield for an angiogram, an X-ray of the arteries to the brain.  My registrar wrote to her after her discharge from hospital to confirm the results.  He was not a great communicator.  His letter started off well: “Dear Mrs. Johnson, I am writing to let you know the result of the X-ray of the blood vessels in your neck.”

So far, so good.  But then: “This shows extensive atheroma extending from the carotid bifurcation to the Circle of Willis bilaterally.  As discussed when you were an inpatient, such lesions are not amenable to surgery.”

I hate to think what Mrs. Johnson made of that when recounting the findings to others.

For a doctor, modern medicine is a strange hybrid of science and clinical skills, which live uncomfortably together like a married couple who don’t get on but cannot do without each other.  Science, of course, leads to medical advances and, by its very nature, is precise.  Clinical skills represent more of an art form taking simultaneously into account the history of someone who is in no position to know the relative significance of one symptom over another, vague or non-existent signs on physical examination and a host of intuitary skills, assessing mode of presentation and body language of the patient.  A doctor needs to assess the significance of what is unsaid as well as what is said.

In the sick room, ten cents’ worth of human understanding equals ten dollars’ worth of medical science.   Martin H. Fischer

The arch proponents of scientific or “evidence-based medicine” as it is known in the trade would probably represent the right wing if medicine were transformed into politics, whilst the poor clinician, battling with soft policies, an uphill battle to get people better and a holistic approach to the patient as a person and not simply a vehicle for disease, would be firmly on the left.  As we have seen, the right-winger can confine himself to situations for which there is a good scientific approach whilst not concerning himself with the witch-doctor methods of his softer colleagues.  Some would argue that, with sufficient scientific advance, and consequent knowledge of the workings and failings of the human body, medicine could conquer all aliments and all disease, disorder and bodily malfunction would disappear forever.  Others are religious.

What happens then is like what happens when we separate a jigsaw puzzle into its five hundred pieces: The over-all picture disappears.  This is the state of modern medicine: It has lost the sense of the unity of man.  Such is the price it has paid for its scientific progress.  It has sacrificed art to science.   Paul Tournier, M.D.

It is true that disease can be conquered.  For probably a few thousand years, smallpox had ruled the roost through most of the world, wiping out anyone it didn’t fancy and disabling many more.  Its authority had overruled King Louis XV of France, Tsar Peter II of Russia and Queen Mary II of England by removing them from their thrones and sending them underground.  It has been said that smallpox killed one child in ten in Sweden and France and one in seven in Russia even by the eighteenth century.  Survivors were facially disfigured from deep scars, known as pockmarks, often blind and decidedly unattractive.

Milkmaids, by contrast, often had unblemished faces and good vision and were pretty, at least relatively so.   The farming community had reportedly long recognised that infection with cowpox from cows’ udders produced only a mild, non-disabling disease but provided protection from the much nastier smallpox.  By the late eighteenth century, the widespread knowledge of the rural population had finally filtered down to the medical profession, at least that proportion that lived in towns.  Dr. Fewster from Thornbury, Gloucestershire, presented a paper to the Medical Society of London in 1765 entitled “Cowpox and its ability to prevent smallpox”.  These observations prompted Edward Jenner to test deliberately the effect of the administration of cowpox on the later risk of acquisition of smallpox.

A milkmaid, Sarah Nelmes, went to see Edward Jenner for treatment of cowpox.  Doctor Jenner extracted fluid from the cowpox pustules and injected them into James Phipps, the eight-year-old son of his gardener.  James contracted a mild case of cowpox but recovered.  The physician then injected him with smallpox but James showed no reaction; he was immune to smallpox.   As a result of this and later experiments, Edward Jenner has been credited with founding the principle of vaccination to provide resistance against infectious diseases.

This story should come with a “Do not try this at home” warning because, these days, Mr. Phipps would be required to provide informed consent on behalf of his underage son with death from smallpox being deemed to be an acceptable outcome and the General Medical Council may have something to say about the ethics of the experiment.  Fee-hungry lawyers may not have much difficulty in establishing a case of medical negligence if something went wrong either.  Anyway, the good news is that these little considerations clearly did not hamper the medical entrepreneurs of the day and vaccination for smallpox was born.

By the early 1950s, approximately fifty-million cases of smallpox occurred in the world each year, but increasing vaccination led to a fall to around ten to fifteen million by 1967.  In that year, the World Health Organisation launched a programme of mass world-wide vaccination which led to formal recognition of the global eradication of the disease in 1980.

The last natural case was in Somalia in 1977.  I always feel sorry for that person – if only the spread of the disease had stopped just one person earlier.

But that’s the only human disease that has ever been eradicated.  Moreover, despite official declaration by the World Health Organisation in 1980 that smallpox no longer exists as an infection of people, the USA (Centers for Disease Control and Prevention, CDC) and Russia (The State Research Center of Virology and Biotechnology VECTOR, also known as the Vector Institute) continue to stockpile the virus.  The official reasons for so doing are in case smallpox comes back and for possible research into resistance against biological warfare.  Quite why this is necessary if the virus doesn’t exist anywhere else is unclear.  Even the provision of jobs for unemployed and purposeless researchers hardly seems an overriding consideration.  The need for techniques to resist smallpox warfare exists only as long as there is a possibility of using smallpox virus as an aggressive agent which exists only as long as the virus is stockpiled.  So we have a wonderful self-reinforcing situation.  Fortunately, potential use of the virus as an active agent of warfare is strongly denied by all authorities so it looks as if we can all rest easy in our beds.

The CDC website informs us: “The September 11, 2001 terrorist attacks in the United States raised concerns about the possible use of biological weapons such as smallpox.  CDC helped prepare for such an attack by working with state and local health departments to vaccinate civilian health care response team members, so they could safely care for patients with smallpox.”

“More than 44,000 people were vaccinated against smallpox as part of the National Smallpox Pre-Event Vaccination Program, launched on December 13, 2002.  CDC’s Immunization Safety Office (ISO) helped monitor the vaccine’s safety.”  Oh dear! How depressing – poor old Jenner must be turning in his grave.

Before closing the subject of smallpox, I should point out that Edward Jenner was probably not the first to use cowpox vaccination against smallpox.  Benjamin Jesty, a Dorset farmer, who had previously had cowpox, infected his wife Elizabeth and their two sons with cowpox in an attempt to provide resistance against smallpox when an epidemic came to Yetminster in 1774. They all recovered and did not catch smallpox.

As rewards for discovering and promoting vaccination, Edward Jenner received rewards from the House of Commons of ten thousand pounds in June 1802, and twenty-thousand pounds in 1807.  George Pearson, founder of the Original Vaccine Pock Institution, gave evidence of Benjamin Jesty’s work of 1774, twenty-two years before Jenner’s, but various factors mitigated against Jesty’s well-documented case and he received nothing.  I expect he’s turning in his grave as well.

In science, credit goes to the man who convinces the world, not the man to whom the idea first occurs.   Francis Galton

Scientific progress in medicine is not lost on patients whose access to the internet has supplanted mother’s words of wisdom as the major information resource, director and comforter.

Tony Ward was referred to me by Dr. Bolton, Consultant in General Medicine, with a suspected diagnosis of peripheral neuropathy.  Peripheral neuropathy is a condition in which the nerve fibres, mostly in the arms and legs, die off and cause weakness and numbness.  The smallest nerve fibres are affected first and the condition then spreads to larger ones, in a pattern similar to the death of small twigs on a tree followed by involvement of larger and larger branches.  As a result, symptoms of peripheral neuropathy start at the ends of the fingers and toes and spread back gradually up the limbs.

It was fairly soon apparent that the diagnosis of Mr. Ward was correct so I began to explain that peripheral neuropathy had many causes and we would need to do further tests to find out more.  At this point, TW dived into his briefcase by the side of his chair and pulled out more paper than I thought the briefcase could possibly accommodate.  His wife was already holding about another half ream, presumably the excess that the poor briefcase could not cope with.

“We googled peripheral neuropathy and came up with some information that you may be familiar with.  However, we thought that we would bring it along for your comments” he said, possibly a touch patronisingly.

I made a quick assessment that, at fifteen minutes’ discussion per page, we could be involved in discussion for about two weeks provided we limited ourselves to eight hours per day.  I hastily tried to steer him back to the more traditional roles whereby I was the giver, and he the recipient, of information.  But I soon began to feel like a medical student being chastised for knowing next to nothing and not even bothering to open a text book in possibly a vain attempt to correct my inadequacy.

“Nobody has checked us for diabetes” he said.

This use of the first person plural “us” and “we” came to be a recurrent component of the discussion, if that is what it could be called, as if his wife had been sucked irrevocably into the whole disease process.

“Dr. Bolton checked your blood glucose and it was normal.  That effectively excludes diabetes” I said, in as reassuring a tone as I could muster.

“Effectively perhaps but not definitely because it depends when the blood test is done.  If we haven’t eaten anything, we can’t have any glucose in our blood.”

“Well, that’s not quite correct Mr. Ward.  In fact, we often check the blood glucose level after a period of starvation as a better test for diabetes.”

“It’s not better in our opinion.”

He fumbled amongst his papers and I fully expected him to extract an article that he would see as the coup de grace to my authority – something like “Fasting Blood Glucose Misdiagnoses Diabetes” by I.M. Expert–Wannabee, MD (failed) in the Journal of Bad Research 1873.  But he had moved on.

“What about acrylamide poisoning?” he offered.  Acrylamide is a chemical used in various industrial processes and can sometimes cause a neuropathy.

“That is very rare.  Have you ever worked in an industry that uses acrylamide?”

“No but it’s present in food” he said, a little too emphatically perhaps.

Indeed, acrylamide is present in food, especially chips and other starchy foods, but how he knew that I don’t know because that discovery was only made in 2002 and we were still in 1999.  I expect he made a lucky guess but, since he was holding a sheaf of a few dozen pieces of paper when he said it, I found it difficult to be sure that the internet had not provided at least some backing for his claim.

“It will not be present in food in toxic quantities” I boldly suggested, hoping he wasn’t going to break into a grin and slap an internet printout on my desk in the manner of a parent beating his child at the game, Happy Families: sympathetic but inwardly delighted at the exercise of superior intellect and control.  Luckily, he didn’t respond and I was safe.

The beauty of the internet for self-researchers is that indiscriminate searches will usually find some site that provides information to back any theory you care to put forward.  Mr. Ward failed to find a backing for his idea that he had been rendered neurologically disabled by McDonald’s fries, not because such support did not exist somewhere, however unreliably, but more likely that he had not searched hard enough.

Teddy Bear’s Triumph Chapter 7 Post 2

 

On the day of my first drive into Boston, it started to snow.  My impression of the USA is that it has more of everything: more land, more mountains, more corn, more coke, more riches, more poverty.  And more weather.  The sun doesn’t just shine; it blazes.  The wind doesn’t just blow; it makes tornados.  And the snow makes British snow scenes look like one of those glass bowls filled with water and containing an endearing scene in plastic that becomes coated in the gentlest of snow showers when the bowl is inverted.

The snow came down in flakes the size of plates, all perfectly vertically, and gathered on the road within minutes.  Sensing something bigger than I might have been able to handle, I called in at the filling station on the edge of Acton.

“Do you think I will make it into Boston this morning” I asked.

“Mebbee” replied the attendant.

“Do you think I will make it back this evening?”

“Mebbee not.”

I went home and tried again when the snow had cleared about four months later.  Well, I exaggerate, but there was a four months’ stay of the snow, not necessarily still falling from the skies but gradually compacting by the roadside and changing by degrees from a virginal white to a dirty grey.

On Monday mornings, I attended the Memory Disorders Clinic where I would see a selection of new patients, assuming they remembered to attend.  The clinic had dual roles: one clinical, to diagnose, treat and otherwise manage the patient; the other research, to spot cases that may be suitable for drug trials.  The commonest cause of serious memory loss is Alzheimer’s disease for which there were, and still are, few useful treatments.  Discovery of a drug that was effective in reversing memory loss or preventing further deterioration would be like gold dust, metaphorically and, for the pharmaceutical company at least, literally.

Will was involved in research on two drugs at the time.  The criteria for entry into the two trials were slightly different, so patients had to be mentally classified on assessment not only into trial or no trial but also trial one or trial two.  Combining these thoughts simultaneously with ones devoted towards care of the patient could produce conflicts of interest.  But since there was no useful drug available, entry into a drug trial was probably the patient’s best option.

I called my first patient, Vernon Gruber, a white male aged seventy-three who attended with his wife.  After the usual introductions, I started on the history.

“What is it that has brought you to see me?”  Fortunately, he didn’t say “an ambulance” as one patient did a few months later.

“It’s his memory” said Mrs. Gruber.  “It’s awful.”

“Do you agree, Mr. Gruber?”

“Suppose so.  I can’t remember.”

“How long has it been a problem?”

“I forget right now” he said.  But Mrs. Gruber was keen to enlighten me.

“Months.  He just doesn’t try.  The son-of a-bitch does it on purpose.”

“How do you know?”

“I haven’t lived with him for thirty-five years without knowing something about him.”

I pondered quite why she had stuck out the thirty-five years when she seemed to dislike him so much but I knew he had changed and her anger reflected her anxiety.

“He’s not the same guy, not at all”, she said more quietly and that summed up her problem.

And then she started to cry.  There is a sweet side to the dragon, I thought.  It’s heartbreaking to see a slow relentless decay of memory in a loved one.  But she soon clarified:

“I am having to do everything now – all the chores, going to the store, cleaning the yard.  And I am not well myself.”

“Who did it all before?”

“Well, he did!” she exclaimed, as if I had asked a silly question (and, given what I knew of this couple so far, probably had).

“You’ve got to do something, doc.  I am going to end up really ill, if it carries on like this.”

I went through the rest of the history, did a physical examination and a brief memory test, identified him as a trial two candidate and turned my attention back to her.  Out of normal courtesy, I spoke directly to him but knew he was not taking it in and so framed my discussion for her ears.

The most likely diagnosis was Alzheimer’s disease I explained but usually the memory loss occurs much more slowly.

“Well, he has been like it for years” she said.

“I thought you said months.”

“Well, he has been like this for months but he has not been right for years.”

“In what way?”

“Bad memory.”

There are times in medicine when you realise that some behaviours defy a rationale explanation and this was one of them.  I gave up aiming for historical precision because I felt that I too would end up really ill if it carries on like this.

He agreed to undergo further tests and so did she – on him, that is.  In truth, he wasn’t really fit to give informed consent and we needed her on board if we were going to do anything to even try and help – which probably meant trial two.

The routine was to meet next to Will’s office after each clinic to discuss the cases.  The venue was a seminar room but it looked more like a boardroom and, on the face of it, had precious little to do with medicine.  In attendance were John, a psychiatrist, the psychology research team from MIT, two research fellows including me, a statistician and a research secretary.  It’s serious stuff dealing with these dementia cases, let me tell you!  Most of the people present said nothing.  Will would ask one of the research fellows to give details of the next case which would prompt what might loosely be called “discussion”, usually consisting of a single statement from Will, “So a trial one player then?”  (To be strictly accurate, there were two variants of this question because it could concern trial two instead.)  The statistician in particular never, to my knowledge, said anything at all but spent the whole time looking depressed, maybe with good reason because it is very difficult to do meaningful statistics on cases presented one at a time.

“So will you speak to Mrs. Gruber?”

(Not if I can get away with it.)  “Yes, of course” I replied.

After the clinic, we returned to MIT.  The journey to and fro was usually carried out on foot over the Longfellow Bridge across the Charles River unless, that is, the city’s air pollution reached a level that risked wiping out half of the population.  Only once in eighteen months was there an official declaration that the city was effectively uninhabitable outside of a hermetically sealed car or a coffin but, on a number of other summer days, I wished I had been wearing goggles to at least limit the corneal erosions invoked by the airborne acids.

At MIT, I shared an office with two postdoctoral fellows (or postdocs as they are known in the trade).  Actually the occupancy was a bit variable.  The three of us were fixed tenants but most of the Psychology Department passed through the office at regular intervals, sometimes staying briefly to chat and at other times taking a seat at one of the desks, without invitation, to edit some research paper they were carrying.  I suspect every other office in the building was used in the same way.  I rationalised that a virtuoso researcher cannot afford the delay between the realisation of some universal truth and arrival back at one’s own office for fear that the intellectual gem will be lost.  So the only answer is to take temporary root at the point of spiritual dawning in order to record the discovery there and then for the benefit of future humankind.  Either that or they were slightly mad – or both.

The principle of the neuropsychology research carried out at MIT was to work out precisely what was wrong with the memory and intellect of someone with damage to a known, specific part of the brain.  By implication, the same part of the brain controlled those functions in people without brain damage.  The non-damaged group are usually called “normal” but anyone who has looked even slightly closely at most “normal” people will realise that the group probably doesn’t exist at all – the whole human race is, to a greater or lesser extent, barmy.  But we were dealing with functions, such as memory, that are not usually considered to be major determinants of barminess so members of the “normal” group are more similar in that respect than you might expect.

Damage to specific parts of the brain produces the most extraordinary effects as now any one of thousands of researchers, books and articles around the world will tell you.  If it didn’t exist, I don’t think you could make it up or, if you did, no one would believe you.  The amnesic can do everything but remember – an ace at the Daily Telegraph crossword but unable to remember anything about it – or even having done it at all – forty-five seconds after he has put it down.  On the whole disabling, but quite handy if you have to spend time with disagreeable relatives; at least you feel good very soon after they have gone away.  One amnesic also pointed out to me that you can have great fun going on holiday repeatedly to the same place because each visit seems like a completely novel adventure.

Mrs. Kennedy had visual agnosia.  She could see perfectly well but she had selective inability to recognise objects.  Ann held up an orange.

“What is that?” she said.

“I don’t know” replied Mrs. Kennedy.

“Can you describe it for me?”

“Yes, it is fairly small, round, a bit knobbly over the surface.”

“Why don’t you hold it?” asked Ann.  “Can you tell me anything else?”

“Well, it is fairly soft, you can squeeze it between your fingers.”

“What colour is it?”

“Orange.”

“Do you know what it is?”

“No.”

The aphasic is kind of the opposite.  He or she knows what the object is but cannot find the word for it.  You can meet aphasics who have difficulty with only one category of object, such as living but not nonliving things.  Who knows what may turn up next?  Inability to name frozen but not non-frozen food?  Green but not red vegetables?  Spouse but not mistress?  I wouldn’t be surprised.

But the best for entertainment value are those with frontal-lobe damage.  The frontal lobes of the brain deal with more complex functions, such as planning, judgement, self-control, and, broadly, personality, which are lost or altered by damage to the area.

Mrs. Diamond, for example, had developed frontal-lobe damage when a pickaxe fell from a shelf and penetrated her skull (sorry if you are squeamish).  She had agreed to come to a case conference attended by most of the hospital consultants in order to discuss her case and thereby fulfil the worthwhile dual aims of education and acquisition of the necessary number of hours of continuing professional development required to remain in medical practice.

Seated on the front row was Matt Digby, a serious radiologist with glossy grey hair, chubby cheeks and no smile.  As Mrs. Diamond entered the room, she glanced briefly at Matt before throwing herself onto his lap, “Aren’t you gorgeous?” being the spontaneous explanation of her behaviour.  If Matt had been capable of looking even less amused than usual, he would have.

It is no surprise that such people (patients not radiologists) used to be locked away in madhouses but even then doctors were smart enough to know that producing a different form of frontal lobe damage would have the opposite effect, production of a compliant, apathetic individual.  Hence was the fashion for frontal lobotomy, which, if pressed for time, could be carried out at the bedside.  Insertion of a metal rod up the nose, through the thin bone at the top that separates the nostril from the brain, penetration of the frontal lobe and a few deft spiralling motions of the rod would soon produce the desired effect.  And very few complaints afterwards.

Teddy Bear’s Triumph Chapter 7, Post 1

Chapter 7:  Foreign varieties

If the grass seems greener on the other side of the hill, it is probably a different species.

Some qualifications are essential to becoming a consultant physician.  For a start, it helps a lot to have a medical degree but, on top of that, Membership of the Royal College of Physicians is a sine qua non.  Then, there are the qualifications that are desirable but not essential, such as a past job in research, properties that provide distinction from competitors with equivalent basic skills.  In principle, anything that allows your CV to stand out from the rest will do, provided it is reasonably moral.

Unfortunately, the more people collect these distinguishing badges, the less they distinguish.  When every applicant has a previous research job listed on their CV, something else has to be found to provide that “little extra”. Life events of increasingly dubious relevance become incorporated into assessment criteria.  An Oxbridge blue in rowing may not be an obvious asset for a senior doctor but it will, if you choose so to argue, help produce a more fulfilled personality and hence a better doctor.  Hmmmm.  It probably also helps if you intend to specialise in the management of rowing injuries.

One popular desirable but not essential qualification in the early 1980s was the BTA (Been To America).  I cannot recall now the post hoc rationalisation that led to the inclusion of this particular experience in the list of desirable attributes, probably because the logic of it was largely irrelevant: the important point was that, at some point, it had proven useful as an arbitrary indicator to distinguish candidates and therefore later became a desirable property for a candidate in the gaining of points against one’s competitors.  As long as the badge was still deemed desirable, it continued to distinguish.  Only when the majority of applicants had collected this particular badge was it necessary to find some other and then, of course, the BTA, like all others, could be removed from the desirable list, only to return when nobody bothered doing it anymore because it provided no tangible career benefit.  Such considerations were even more important if there was the intention of working in a particular city, as opposed to any that proved sufficiently magnanimous to offer employment.

On Friday, 14 January 1983, my wife and two-year-old daughter waited in a queue at Heathrow Airport, ready to entrust our six suitcases, representing a mobile embodiment of our current life, to the check-in clerk.  Actually, to be strictly accurate, my wife and I waited and my daughter waited intermittently.  Soon we would be following in the footsteps of the Pilgrim Fathers to the Land of the Free to settle like them on the eastern seaboard at a place now called Boston.  The trip was no doubt essentially similar to theirs except in minor detail, such as a jet airliner, hotel on arrival and alcoholic drinks en route.  (Dear Reader, I have not troubled you with the details of the courtship and marriage of my lovely wife and the arrival of my beautiful daughter.  Suffice it to say for the purposes of this account that both were acquired by fairly traditional means.)

William Jackson, my American mentor-to-be, was to meet us at the airport and take us to the Holiday Inn in Somerville, which we had booked before departure.  When we spoke on the telephone before departure, he told me he had never heard such a classic English accent.  I wondered whether to reciprocate by praising his American accent but felt uncomfortable with the notion that this was a compliment.  I am glad I didn’t because I was reliably informed some months later (by an American) that Americans don’t have an accent; but the English do.  Strange, isn’t it, how normality becomes defined from one’s own perspective?  Incidentally, North America is probably the only English-speaking region whose inhabitants make no distinction in the pronunciation of Mary, merry and marry (although this does not apply to Boston).

I would recognise Will, he told me, because he had no facial hair and would be wearing blue jeans.  As these features were presumably identified in order to distinguish him from the crowd, I pondered on the appearance of all the other Bostonians: besuited and bearded?

I did not know then that “blue jeans” are to the US what “jeans” are to the UK so I told him that I too lacked facial hair and would probably be wearing green jeans.  I expect he thought I was taking the piss.  Perhaps, however, he knew more English than I did American because, on arrival at the airport, he strode forward, wearing blue jeans and lacking facial hair, to greet us with an air of recognition similar to that bestowed when meeting a long-lost friend.

His face fell only twice.  Once was at the realisation that his station wagon was to accommodate two adults, a child and six suitcases as well as himself.  (I thought of offering to leave the child behind but felt this may label me as a negligent parent).  The second was when he learnt that our hotel was in Somerville.  I still don’t know whether it was the distance from the airport that bothered him or the low tone of the neighbourhood. I discovered later that Bostonians pride themselves on being of original American stock (apart from the native Americans, that is) and convey an impression, deliberate or otherwise, of class-consciousness.  Maybe Somerville was a place that the Jacksons simply do not visit – because that’s how it is.  But the Bostonians are also friendly.  And they have a remarkable capacity to dissociate the personal from the professional.  More than once have I heard an employee being dismissed, only to be invited by the same person to a party a few minutes later.  Will was very much like that.  He drove us to Somerville without complaint.

I suspected that any apartment that we could afford in downtown Boston would be a cockroach nest so we chose to rent in a small town called Acton, twenty miles out.  Acton was mostly one street, lined by single-storey shops, but it had everything required, including an Italian restaurant, liquor store and guitar school.  The apartment building grounds also included a swimming pool, supervised by an attractive young female lifeguard, who befriended my daughter (but not me).  We rented furniture, raided the local store for crockery and cutlery, used sheets as curtains and were thereby mostly set up.

Except for transport.  Maintenance work was underway on the railway line to North Station, causing disruption to a direct journey from home to Boston, where I would work each day.  There seemed little choice but to buy a car.

The man in the used-car lot was short but his hair was long and he sported a moustache that seemed too big for him in general and his face in particular.  The effect was exemplified by his lack of facial movement, his lips being held clamped together in the guise of someone holding total contempt for everything and everyone around him.

There seemed no question of considering any car that he had not personally selected for us.  His descriptions were all brief and largely paraphrases of each other.

“Chevrolet.  Three litre.  1973.  Fifteen hundred bucks.  A beauty” or something very similar.

I was tempted by a geriatric Lincoln Continental 7.5 litre that looked as if it accommodated about eighteen people, all supine, had a suspension similar to a waterbed and did about two and a half miles to the gallon.  These cars were icons of past times but rejected by many people on average salaries because of lack of affordability.  And that’s why I opted for the 1200 c.c. Renault 5.  Mr. Disenchanted reacted as if I had ignored his tip of the sure-win rank outsider at the Grand National.  However, he agreed to sell the Renault, probably because we were mad English and at least he was making some money.

“Anything else I need?” I asked as the deal was done, my licence was checked and insurance organised, all on the spot.

“Like what?” he growled.

“Road tax.”

“Road tax??!!” he blurted, eyes on fire.

“Yes, in the UK, we have to pay road tax.”

“Well, don’t mention it here or someone’ll sure think about it.”   That was the longest sentence he produced over the course of one and a half hours.

I drove away, pleased at having legally avoided road tax and a little proud at having chosen a European car, even though it had about a quarter of the seating, power and comfort of the Lincoln and none of the panache.  At least, I wouldn’t have to fill up with fuel every twenty miles.

An American is a man with two arms and four wheels.   A Chinese child

Three days later was to be my first full day in Boston.  With a clinical and research fellowship, I was to divide my time between seeing patients at the Massachusetts General Hospital and doing research at Massachusetts Institute of Technology.  Will’s specialities within neurology were memory and movement disorders, mostly Alzheimer’s disease and Parkinson’s disease so, perhaps not surprisingly, these were the patients I saw.  Just a few months earlier, I had had to take and pass the Visa Qualifying Examination (VQE), which tested my knowledge in all the basic subjects of the medical course, including specialities such as gynaecology that I had not visited, at least in a professional capacity, since my student days.  Fresh from the mind-broadening experience of yet another exam, I felt a little disappointed at having now to restrict my intellectual energy to subspecialities of neurology.  I could easily have thrown in a few vaginal examinations along the way.

Apart from having to satisfy the American authorities that I was proficient in medical areas with which I was never to have any dealings, I was also required to demonstrate my linguistic skills by taking an English test as part of the VQE.  It seemed a very odd requirement until a large American psychiatrist explained to me later that it was really a test in American.  I still felt sure that American was an easier language to learn for an English speaker than French, in which I had had no testing when I worked in a Parisian hospital for a few months, four years earlier.  By the way, the VQE application form required identification of nationality at three different times of life: birth, on entering medical school and on leaving medical school.  I am still not sure whom that was supposed to catch.

Health care in the United States is mostly operated by the private sector and funded by insurance companies but many people are uninsured and the problem is getting worse.  A US Census Bureau report indicates that about thirty million people or roughly thirteen percent of the population had no health insurance in 1987, three years after I was there, and the first year that data were collected.  Interestingly, by 2009, the figure had increased to 50.7 million or 16.7 percent of the population.  Hinnelstein and colleagues, reporting in the American Journal of Medicine, showed that 62.1 percent of all bankruptcies in 2007 were medically related, either because of loss of income due to illness or having to pay medical bills.  In 1981 the figure was eight percent. The share of bankruptcies related to medical problems had increased by 49.6 percent from 2001.   Ninety-two percent of medical debtors had medical debts over five thousand dollars or ten percent of pretax family income.  The average medical debt for uninsured people in 2007 was nearly twenty-seven thousand dollars.

Financial ruin from medical bills is almost exclusively an American disease.   Roul Turley

Ellie May lived in a rented apartment of our building with her husband and daughter, Lori.  Mom and Dad were in their early twenties; Lori was aged four.  Ellie May did not have a job; the current Dad gained just enough income from labouring jobs to pay the rent, feed the family and cover other household costs.  But it would all have been a lot easier if they were not saddled with a debt for fifteen thousand dollars for medical costs related to an accident he had at work two years earlier.  The nature of his work did not provide for any employment-related insurance and they could not afford to pay premiums themselves.  All they could now manage was to pay the interest on the loan; there was not the remotest chance of their ever paying off the capital sum.  Quite what they would do if they were to become ill in the future is, as they say, not at all clear.  Some respite existed in the form of Medicare, a Government programme, if they were lucky enough to reach the age of sixty-five, and by Medicaid if they could engineer their poverty to combine with one of the other criteria of the programme, such as disability.  So, hey, all was not lost.

I recently became a Christian Scientist.  It was the only health plan I could afford.   Betsy Salkind

Teddy Bear’s Triumph Chapter 5 Post 2

Patients come in all shapes and sizes, literally and metaphorically.  Not surprising, perhaps, because, on the whole, they represent a cross section of society.  It is amazing how difficult it is to get people to change their physical and mental habits, even if it is to their advantage.

Obese people tend to present to clinics dealing with heart disease, high blood pressure and diabetes.  Appeals to lose weight for their own sake are met with a variety of responses:

“I’ve always been big.  My mother and sisters are big.”

“I tried and I can’t.”

“Well, I know somebody half my weight and they still got diabetes.”

“I just like my food.”

Some doctors go to extreme lengths to get their patients to lose weight.  I knew one consultant who told his overweight patients “There were no fat people in the Belsen concentration camp.”  Maybe he got away with it because he was Jewish.

But I have some sympathy with the patients’ responses.  It is not the responsibility of the doctor to dictate how someone should live but they do need to point out the risks of the particular lifestyle.  I had a patient who had been sent from another consultant for a second opinion on the reason that he had developed double vision.  None of the tests had provided the answer but routine blood tests had shown abnormal liver tests, almost certainly because the gentleman’s main recreational pursuit was alcohol ingestion.  I happened to mention the test results, as previous consultants had done, and he admitted that he drank to excess but chose to do so because he enjoyed it.  The abnormal liver function tests were not going to put him off.

He added, “You doctors are an interesting lot.  I come to see you about a problem with my eyes and get the response ‘I’ve no idea what’s wrong with your eyes but I recognise a dodgy liver when I seen one.’”  So maybe the spherical suet pudding who likes their food should be allowed to continue liking their food, food and yet more food, provided they understand the risks attached.

By the way, the claim that it is impossible to lose weight might just be correct.  I had always thought that a person could not possibly be so large without eating constantly throughout the day unless there was something physically wrong with their metabolism.  I have seen a lot of very large people walking into the local swimming pool but have never seen any of them carrying burgers or sandwiches at the time.  I doubt that it is original, but I had a thought that the problem might be due to a virus.  Low and behold, in 2007, Professor Richard Atkinson, building on work by Dr Nihi Dhurandhar in 1992, found evidence to support infection by the virus Ad36 as a cause of obesity.

But it is the different personalities of people that make medicine at once fascinating and frustrating.

It has often been said that the most important part of medical assessment is the taking of the history, that is the patient’s account of the nature of the symptoms and how they unravel over time.  It may be that this notion has been particularly nurtured by doctors who cannot be bothered to examine patients but there is little doubt that there is some truth in it.  It is important not to ask leading questions because some people will agree with everything suggested by the doctor because of awe, anxiety, desire to help or simply not listening.  Unfortunately, this reluctance to pin down the patient verbally can lead to major difficulties in obtaining necessary information.  A fly on the wall helpfully recorded this conversation for me:

“When did the headaches first start?”

“About the time of my sister’s wedding.”

“When was your sister’s wedding?”

“Just before the headaches started.”

“How long ago was that?”

“Oh, I don’t know really.”

“Well, was it months or years?”

“Not years, oh no!”

“Was it less than a month?”

“Oh no, it was longer than that!”

“So it was several months ago?”

“If you say so, I suppose it must have been.”

“I know it is difficult to describe headaches but what sort of pain is it?  What do you feel in your head?”

“Terrible.”

“Yes, but is it a throbbing, tightness, stabbing or what?”

“Yes.”

“Which?”

“It’s just awful. I’ve got it now.”

“Did anything unusual happen at the wedding?”

“She had four pageboys, which I thought was a bit unusual.”

“No, I mean anything that you think might have caused the headache”

“I don’t see her much now because they went to live in Australia.”

Chloe Critchley posed a different problem for the history taker.  It was not so much that she failed to answer the questions in whatever format they were posed but her answers were so mundane as to have virtually no meaning.

“How are you today?”

“Can’t complain.”

“How have you been since your last appointment?”

“Well, a bit up and down I suppose.”

“Overall, have you been better or worse?”

“You win some, you lose some.”

“Are you still getting migraines?”

“Well, what goes around comes around after all.”

“Are they getting you down?”

“Worse things have happened at sea.”

“How often are you getting them now?”

“Once, twice, three times a month who knows, even I don’t know everything!”

“How much are they affecting your life? How much time are you having to take off work?”

“I like work it fascinates me.  I can sit and look at it for hours, I think that is a famous quote”, she said laughing.  “I do what I can.”

“Are you happy with your present treatment? Would you like to try something else?”

“Better the devil you know …”

And so it went on.

I ended up calling her Cliché Critchley although not to her face, of course.  There is a condition caused by a problem with part of the brain at the front that leads people to make repeated silly jokes, often out of context.   I wondered whether I had found something similar in Cliché Critchley and pondered whether I should persuade her to have a brain scan.  But, I pondered, how was I going to explain to her the reason for this?  After all, she didn’t have a definite problem and I had no desire to give the neo-fascist impression that I thought that she was so mad that she ought to undergo investigation.  I decided it was just her personality and left it at that.

Most people of course, answer questions well and to the best of their memory.  Indeed, the taking of the history should not really be a grilling of the patient by the doctor but more a conversation in which the patient is allowed to give an account of their symptoms freely with prompts where necessary by the doctor.  Some people are remarkably clear.  Occasionally, the answers can be so precise as to stretch the credibility that a person can have a memory that good.  Jack Taverner was one such person. He had developed tingling in the hands and feet with some loss of dexterity.

“When did the trouble start?”

“May 17, 1978.”

“That’s very precise.  Did something special happen that day?”

“No, I just remember it.”

“What happened then?”

“I got tingling in the fingers of the left hand except the ring finger and in the right hand except the middle finger.”

“And when did you start having difficulty in using your hands?”

“Eight weeks and four days later.”

“Have dropped things from your hands?”

“Yes, five times.”

“When was the last time?”

“February 6, 1979.”

I wondered whether he was making it up but I had no way of knowing.  Some years later, I came across a similar pattern of behaviour whilst doing some research on memory.  The test involved giving the subject a cue word such as “apple” and asking them to recount a memory from their own life, however trivial, connected with that word.  Again, I observed the same pattern of extremely precise answers from one subject to the extent that it was virtually beyond one’s imagination how the memory could be so good.  Unlike Mr Taverner, however, on this occasion I had the opportunity to ask the same questions the following day as part of the test procedure.  He gave exactly the same answers.  Thus, either the answers were true or he had remembered on the second day the answers that he had given on the first day.  The latter seemed very unlikely because he was not warned that he would be asked the questions the following day and again his memory would have to be remarkable to remember such detail.

I concluded that he and Mr Taverner had an extremely precise memory for detail.  The difference between the two patients was that the man on whom I was carrying out the memory research had had a brain injury.  It was fascinating to think that somehow damage to a particular part of the brain had improved rather than compromised particular aspects of memory.  I was reminded of the person with high functioning autism who can learn large quantities of unconnected information, such as a telephone directory, a feat that is beyond the capability of most ordinary people.  Once again, I wondered whether I should have carried out a brain scan on Mr Taverner.

But what physician has not had patients who don’t make any sense at all? To tell the truth, they’re our stock-in-trade. We talk and write about the ones we can make sense of.  Walker Percy

Teddy Bear’s Triumph Chapter 5 Post 1

Chapter 5:  Blossoming

Blossoms are attractive fronts for the mundane.

Wednesday mornings at the Radcliffe Infirmary were spent for me in Neurology Outpatients.  The clinic started at nine and first on the list was Myrtle Musgrove.  This was potentially bad news because I had been in my registrar’s post long enough to have seen Myrtle on several of her regular three-monthly visits.  Having her first on the list threatened to destroy the whole of the clinic because we had follow-up patients booked every fifteen minutes and she wouldn’t get out of bed for a consultation of less than thirty minutes, whatever problem she had.  I don’t know why none of my predecessors had discharged her from the clinic because it had become fairly clear to me after just a few visits that, although her condition was not perfect, it was unlikely that we were going to be able to do anything further to help her, for a variety of reasons.

Myrtle Musgrove had epilepsy.  She was quite unusual because the condition had begun in her sixties and investigation had not shown any reason for the epilepsy, as is often the case in older people but much less with epilepsy of young onset.  The unfortunate fact that all the investigations, including brain scans, were normal, did little to assuage her belief that “something was going wrong in her head.”  Indeed, it was and I tried to explain that the seizures were arising at a microscopical level, similar to an electrical short circuit, which need not show on tests such as brain scans.  Unfortunately, this admission of a brain abnormality accompanied by normal test results became magnified and extended to the notion that she had a nasty brain tumour which did not show on the scan, a point of view that she argued with considerable ferocity against any view to the contrary.

She always came with her husband whose anxiety levels exceeded even hers.  In fact, she denied having any emotional reaction to her condition at all; “I am quite a strong woman really” she would repeat at each visit, with the characteristic posture of raised eyebrows, closed eyes and head tilted to the left and upwards, her greying black ponytail drooping over her right shoulder.  She was a slight woman with a gaunt face, pointed nose and pursed lips.  She rarely smiled and, when she did, somehow managed to convey the impression that you should feel guilty at having provoked such an unwanted reaction.

He, by contrast, was tall and large, but not fat, with a round ruddy complexion and an expression that switched randomly from frowning concern to bright-eyed laughter.  The concerned expression was universally the one that began the consultation as his wife walked regally through the consulting room door and he followed behind, clutching a sheaf of papers, that recorded in detail every attack that she had had since her last visit.

“We have had some more doctor” he said woefully, shaking his head.  “I wonder if we should change her treatment.” This suggestion occurred at every consultation and I was never sure whether his opinion on the matter was shared by her.  She certainly never gave any indication.  In fact, she spent most of the consultation either in complete silence, avoiding eye contact, and with little movement, simply being the third party subject of discussion by others.  When the conversation between Jim Musgrove and me became animated, she showed such little reaction that the whole scenario had the air of fierce bidding over an inanimate object at an auction.

He prodded the sheets of papers lying on the desk, St James’ Epistle to the Neurologists, Chapter 14.  “You can read all about it there.”

Of course, I felt sympathy for Mrs Musgrove and would wish that she did not have any seizures at all.  But she had them only once every two months and they were really quite mild, lasting for only one to two minutes with just a little stiffening of the body.  She did not have the violent convulsions and falling to the ground that most people associate with epilepsy.  The other problem was that she was completely intolerant of all medications that we tried.

“Well, we could increase the dose of her tablets but we tried that before and she became dizzy and dopey.  That does not mean that she would get the same side effects now” I said more with optimism than realism “but there is obviously a risk.”

“I know, I know” said Mr Musgrove, shaking his head.

“She is just tolerating her present treatment. We could change to another treatment but we have tried three other medications in the past and all of them made her dopey” I explained.

“I know, I know” said Mr Musgrove, shaking his head.

“I think I must have a sensitive brain” interjected Mrs Musgrove in her unique resigned tone “but I think I am quite a strong person really.”

By now, my clinic was running fifteen minutes late.  I went over the options again, keeping things as they were and accepting that at least the seizures were relatively mild and infrequent, increasing the dose of her present treatment or changing to another.  After a few pauses broken by heavy expiratory gasps, Mr Musgrove said, “I think we had better stay as we are.”

“I think so”, said Mrs Musgrove.

The consultation ended and we decided to review the situation in three months time.  I did not voice the possibility of leaving the appointment open and having her come back only if things changed, on the grounds that the situation had been essentially similar for several years, because I did not have the time.

Outpatient clinics provide a much greater cross section of illness than hospital admissions because the latter are either emergencies or people who have been selected for further investigation.  People also get better, which may be one reason why a proportion of booked patients at every clinic fail to attend, DNAs or “did not attend”, as they are known.  The DNA rate varies enormously but can be as high as thirty percent.  Interestingly, the rate always goes up during the period leading up to Christmas, presumably because the pressure of catering for the in-laws and the building of little Johnny’s flat-packed trampoline afford no time to be ill.  I once thought that a stress-free, profitable occupation would be to run a private clinic that specialises in DNAs.  Appointments could be put at one-minute intervals; a modest charge could be made for each failed attendance; and all the letters to the general practitioner would be the same: “Your patient failed to attend his/her appointment for the clinic today.”   A nice little earner, really.

At twelve o’clock that day, as I felt like winding down during the last hour before lunch, I had one more new patient to see.  I called in Mrs Dixon, who was a thirty-two-year old, slim, attractive, well-dressed woman with thick, shiny blonde hair flowing gently just onto her shoulders.  Despite her attractive well-groomed appearance, there was something not quite right about her.  She hardly smiled and her face showed little spontaneous movement.  She barely altered her position throughout the whole of the consultation.

My initial impression was that she might be depressed, a thought which filled me with some selfish anxiety because I knew that it can be difficult to unravel symptoms due to depression from those due to physical disease.  People with depression or other psychological problems do not necessarily just feel bad in their mind but they also develop real physical symptoms that do not have a physical basis.

She told me that she had developed pins and needles in her feet approximately six weeks previously but herself admitted that she thought they might be caused by stress.  It didn’t take long to find out why.  Twelve weeks before, her father had died suddenly.  She was emotionally very close to him and took his death very badly such that she had to take sick leave from work.  During the two weeks that she was away from work, her manager effected a reorganisation of the department that had been planned for several months and took the opportunity to make her redundant.  She believed that the reorganisation was an excuse to dismiss her because they had not got on well together for some time and her sick leave had acted as the final straw for the manager.  She was contemplating taking the matter to an industrial tribunal but realised that she would not be paid in the interim, even if her application was successful, and she and her husband would be dependent for the foreseeable future on one instead of two incomes.  Six weeks before my consultation, her husband was killed in a car crash.

She had been in very good health before all this.  She did not smoke or drink excessively and went running in her local woods at least three times each week.  The only problem she had had, and that was not really severe, was that she had blurred vision in one eye for a few weeks about four years previously.  She had no other symptoms apart from the pins and needles.

It seemed most likely that her symptoms were stress-induced but I explained that it was necessary to carry out a neurological examination to ensure that there were no signs of physical disease.  I went through all the routine tests, including movement of the eyes, visual acuity, strength and coordination and found nothing wrong.  However, when it came to testing the reflexes, it was obvious things were not right.  Reflexes are enlisted by tapping a muscle tendon gently with a rubber hammer, which results in contraction of the muscle and jerking of the limb, as in the familiar knee jerk. The reflexes in both legs were much brisker than those in the arms.  That in itself is not definitely abnormal but two further reflex tests confirmed the problem.  I pulled the foot upwards at the ankle using the palm of my hand against her sole.  This manoeuvre does not usually produce much in the way of a reaction but, in her case, the foot went into rhythmic up-and-down movements as long as I kept the pressure on her sole, a phenomenon known as clonus.  For the second test, I stroked the sole of the foot gently with a key.  The reflex reaction is usually for the big toe to move downwards but, in her case, it moved upwards towards the face.  Both of these signs indicated definite damage to the nerves that travel down through the spinal cord to the legs and showed that she very probably had something wrong with the spinal cord to cause those reflex changes and also to explain the pins and needles in the feet.

And then something registered in my mind that would have been obvious to someone with more experience.  The loss of vision that she had in one eye a few years previously was probably optic neuritis, a warning of a potential future neurological disorder.  It was clear that, over a period of twelve weeks, not only had she lost her father, husband and job, but she had also developed multiple sclerosis.

Manchester May 2017

Limbs thrown as garbage

Against the kiosks

And people;

Walkways now blood puddles,

Concentrated by hatred

And diluted by tears.

 

Explosions: then people ran

But to nowhere

And everywhere

At once.

Where to find safety?

And reason?

 

The homeless and privileged

Joined in a vice of emotion

And aid;

And the concert came back,

The concert of music

And resistance.

 

In the name of love,

Of God, the terror was done;

An attempted blight of humanity

That suffered

And love

That survived.

 

So, not well done, you outside men,

Gains are judged by its losses.

Evil that gains

On the day

Faces love of humanity

That rests eternal.

Do We Not All Choose

 

Do we not all sometimes choose the darkness

When lights of civilisation betray us?

Constraints of order may tax us

But escape has no mercy.

 

Waves beat the sands which complain not;

Clouds move where the winds may take them;

Winners may rise from trials of conflict

But last they will not.

 

Shadows provide cover from visions of reality

Yet harbour that which dwells on the lost.

Open space seems free field for ambition

But will temper success.

 

Do we not all plan for the future

And drain emotion for goals that are lost?

Yet the sands will still rest when we’re beaten

And the clouds will keep place in the sky.

Teddy Bear’s Triumph Chapter 4 Post 4

Chapter 4 Post 4

I decided as a student to specialise in paediatrics but, after qualification in 1972, the higher authorities had decided for some reason that it would be useful for doctors specialising in disorders of children to have expertise in disorders of adults as well.  Thus, budding paediatricians had to gain higher qualification in adult medicine before being let loose on children.

The big hurdle for the embryo physician after the medical degree is the examination to gain Membership of the Royal College of Physicians (MRCP).  Surgeons have their equivalent Fellowship of the Royal College of Surgeons.  Until relatively recently, doctors in all specialities had to belong to one or the other college in order to gain specialist status but increasingly specialities other than general medicine and general surgery have wanted to break away and set up their own empire elsewhere.  This is not necessarily a bad thing because, after all, if the Pilgrim Fathers had not had a similar spirit of seeking independence from the Motherland, we would not have the United States of America, with all its virtues, such as Disneyland.

It is not entirely clear why equivalent levels of postgraduate skill and experience are recognised as Membership of the Royal College of Physicians (RCP) but the superior-sounding Fellowship of the Royal College of Surgeons.  The RCP does have a Fellowship grade but that is granted years later at the discretion of the College.  Maybe surgeons feel that their postgraduate qualification is fundamentally more important than that of the physicians and demands a more meritorious title.  Maybe physicians feel that they are capable of ongoing skill development throughout their career, unlike the surgeons; hence, a more senior title is available to recognise this progress.  Sadly, the truth is probably nowhere near as exciting and the reason for the difference lies somewhere in history.

The RCP was founded in 1518 when the King was petitioned by a group of physicians led by Thomas Linacre.  Its purpose was to grant licences to practice medicine and oust bad practice.  The first college was sited at Amen Corner near St. Paul’s Cathedral, an address which hopefully does not reflect on the destiny of patients treated by the College membership.  The founding charter stated that the College aimed to “curb the audacity of those wicked men who shall profess medicine more for the sake of their avarice than from the assurance of any good conscience, whereby many inconveniences may ensue to the rude and credulous populace”. The College refused to admit candidates from non-Oxbridge universities until 1835 despite an approximately seventy-year battle on the subject.  Women were excluded until 1909 but further delays ensued and the first female fellowship was granted in 1934.  Not much really changes in medicine.

In the sixteenth century, surgeons were linked up with barbers in the Worshipful Company of Barber Surgeons.  Barbers not only attended to the hair and shaving but were also involved in surgical, medical and dental treatments, especially after the Pope decreed in 1163 that members of religious orders should not be involved in the shedding of blood, a practice that was widespread at the time for the treatment of a variety of medical conditions.  Surgeons did not have a medical degree or indeed any formal qualification, unlike physicians who had a university medical degree.  The surgeons broke away from the barbers in 1745 and, in 1800, a royal charter was given to found the Royal College of Surgeons in London followed by the Royal College of Surgeons of England in 1843.

The Royal College of Physicians insisted that candidates for the surgical college must have a medical degree first.  Thus would-be surgeons had to qualify in medicine and received the title “Doctor”.  Rumour has it that, once they gained Fellowship of the Royal College of Surgeons, they reverted to their old title “Mister” so as to snub the physicians’ college.  The tradition of change of title on gaining Fellowship has continued to the present day although the reason has been glossed over in history.  The Company of Surgeons that was founded when they broke away from the barbers in 1745 had its premises close to the Old Bailey and Newgate Prison but hopefully this was not designed for the convenience of the fellows travelling between the two.

Physicians diagnose and treat.  Surgeons cut and used to be barbers.

The MRCP examination used to be in two parts.  The first was a multiple-choice written paper but the second was a clinical examination involving real patients.  The two parts were really separate examinations because part two could only be taken after a pass at part one and the two sections were usually taken about twelve months apart.

The only memorable thing about part one is the marking system.  One point was given for a correct answer, zero for no answer and minus one for a wrong answer.  Whoever dreamed up that scheme is a virtuoso in sadism because the anguish involved in trying to find the correct answer is bolstered by an undercurrent of anxiety as to how confident one is about it.  If unsure of an answer, do you leave it out and get zero or risk being given minus one which effectively wipes out a previous correct answer confidently produced?  If the pass mark is fifty percent, the marking system allows a score of seventy-four percent correct and twenty-six percent incorrect, with no omitted questions, to fail but fifty-one percent correct and forty-nine percent unanswered to pass.  The system might have had some merit if the questions were all life-or-death type but they weren’t.  But, you know, if you want to belong to a club you have to play by the rules.

And though the rules of the road have been lodged, it’s only people’s games that you got to dodge; and it’s alright, Ma, I can make it.   Bob Dylan   “It’s alright, Ma (I’m only bleeding)”

Part two of the MRCP examination consisted of a clinical part and a viva.  The clinical section had two components – long cases and short cases.  These terms did not refer to the size of the box that would carry off the patient in the event of a less-than-ideal treatment plan but to the length of the clinical assessment.  We were allowed about an hour on our own with the patient to take a history and carry out an examination, after which we would present our findings to the

examiners and await interrogation and destruction.  In the short cases, we were taken to a number of patients, one at a time, and were required to examine a particular bit of their anatomy in full view of the examiners, to say what we had found and await interrogation and destruction.

The clinical exams take place at a number of hospitals throughout the country, depending upon whether some keen consultant or other has offered their services to provide an examination facility where they work.  The set-up requires no fancy apparatus, just a ward, usual doctors’ tools such as a stethoscope and, most importantly, a supply of patients with a variety of conditions each characterised by some key physical signs for the candidate to detect.  The patient must be willing to attend on the examination day.  The organisation involved, with its necessary advance planning, usually meant that the patients in the exam were not plucked at the last minute from the Intensive Care Unit, breathing their last, but travelled from home where they lived with a stable but probably largely incurable medical condition, blessed with good physical signs.

Many of these patients came up willingly year after year, for largely philanthropic reasons because they received no reward for their services, unless you count the beaming smile of their consultant as some form of recompense. Contrast this situation with that of volunteers for trials of very new drugs.  In the first phase (but not later), people are paid for taking a drug previously tested only in animals.  The participants are usually required to live at the testing centre for anything up to one month, to take the drugs and undergo regular tests, especially of toxicity.  Not many people can accommodate this schedule easily into their life for fear of conflict with their employer, spouse, child or cat but the homeless tend to welcome a few bucks and nights in a warm hospital bed. The inconvenience of taking a potentially lethal drug is apparently worthwhile.

One wonders whether the medical background of the homeless volunteers, which in truth tends to include greater-than-average quantities of alcohol and drugs, is representative of the population who will later be given the treatment.  One might wonder further whether the conclusions drawn from these studies can be extrapolated to the general population but we are assured by the pharmaceutical companies that everything is just dandy.  Anyway, lots of other people get to test the drug at a later date so there is plenty of opportunity to poison all kinds of different people.  Actually, the truth is that these trials, at least in the later phases, are so rigorous that one sometimes wonders how suitable volunteers, who are not excluded for some minor coincidental condition or treatment, can be found.  This rigor is one reason why it takes so long between discovery of a new drug and its appearance on the market, available to doctors to prescribe.  Another reason is bureaucracy.

Anyway, back to the MRCP examinations, which did not have these restrictions.

I was allocated to a hospital in Croydon, Surrey for my examination.  Living in Sheffield, I thought the choice of venue to be what we in the medical profession call inconvenient but I didn’t say so.  My reasons for thinking so, however, were that the route to Croydon involved a train journey from Sheffield to St. Pancreas Station, London, an underground trip along Victoria Line to Victoria Station, a further railway trip from there to East Croydon Station, a twenty-minute bus trip and a walk, features that arguably satisfy well most definitions of inconvenience.

Arriving early, I found a female soulmate who seemed to be the only other MRCP candidate at that hospital that day.  I think she had travelled from Aberdeen or possibly somewhere more distant.  We sat on a grassy bank in the blazing sun in conversation for what seemed to be hours until the examiners or their minions called us for a grilling.  We were certainly together alone for long enough to have satisfied all the requirements for a chat-up session but we had too much on our minds to follow it through.  Anyway, a relationship exercised between Sheffield and somewhere even further north seemed impractical.  I wondered whether the examiners plan all this sort of thing in advance to prevent amorous associations developing out of their serious professional endeavours.

Real love stories never have endings.   Richard Bach

I was introduced to my long case, Mrs. Hetherington, a pleasant woman of about forty years who was so relaxed and confident that I assumed she had either done this a million times before or was an actress.  (Incidentally, these days, the “patients” are often actors and actresses but were not then.)  I concluded, after some enquiry, that she had had a brain haemorrhage many years previously.  A sense of self-satisfaction on my part induced a state of calm almost to match hers.  I went on to conclude my history taking with the routine questions that included details of her past medical history.

“Have you ever been in a hospital for anything else?” I asked.

“I have been a number of times for tests on one of my eyes”, she replied in a tone of deliberate mystery.  Sensing atmosphere, I felt an impulse to enquire more deeply.

“What was wrong with you?”

“Nothing really but they saw something that they felt needed investigation.”

“Did they see it through one of these?” I asked, showing her an ophthalmoscope, which is routinely used to examine the inside of the eye.

She smiled and said simply “Yes.”

“Do you mind if I have a look?”

With her agreement, I shone the light into her right eye and examined the retina at the back of the eye.  I saw nothing amiss.  I leant slightly over to the left and whispered in her right ear “Which eye was it?”

“The left”, she said with a low, ponderous voice that led me to conclude that she was enjoying a small conspiracy at the expense of the examiners.

As I began to examine the left eye, she moved it into a position that she had evidently learnt best demonstrated the abnormality to an observer such as me because at once I saw, right in the centre of my view, a tangle of abnormal blood vessels, known as an angioma.  Then it clicked.  Because these vessels are not normal, they are fragile and tend to bleed easily.  A similar one inside the brain could have explained her earlier brain haemorrhage.

The examiner seemed satisfied when I offered the diagnosis, albeit tentatively, of Von Hippel-Lindau syndrome, a rare congenital condition characterised by the presence of multiple angioma-like cysts in different parts of the body.  It is amazing what reading does for education because it is only in books that I had come across the condition before or, for that matter, since.  It is also amazing what diagnoses MRCP examiners thought would be a good testing ground for practical medical skills.  I assume it must be more exciting to examine on a condition that not many people are likely to come across ever again than acid indigestion or catarrh, which are common but boring.

The prowess of Mrs. Hetherington and me in the long case seemed to make the examiners positively sympathetic in the short cases.  As I gave a half-baked account of the heart condition responsible for the murmur I had detected in a twelve-year-old boy, one of the examiners stopped me abruptly.

“Dr. Sagar, how would you describe the colour of the patient?”

Remembering that this was a clinical examination, I refrained from commenting on the racial origin of the person under discussion and replied “Blue, cyanosed.”

“Exactly” he said triumphantly.  “And what does that tell you about a possible shunt in this young man’s heart?”

“It’s going from the right side of the heart to the left.”

“Exactly!” he said with a shade more triumph. “Now can you tell me the origin of the murmur?”

We established together that our young man had congenital heart disease and again together worked out how it was producing noises heard through the stethoscope.

I have never found out whether it has any statistical basis but it used to be rumoured that pass or failure in the short cases was closely related to the number of patients seen.  Less than three led to a fail and five or more would be a sure pass.  It reminded me of my history teacher at school who marked the essays according to the number of pages written, leading most of the class to copy large chunks from the textbooks, confident of thereby getting a high mark.  Anyway, I saw four cases.

The viva was taken at the College premises.  My first interrogator informed me proudly that he was a cardiologist (I resisted the temptation to applaud) and so he was going to ask me about cardiology.  I could not fault his logic.  The second interrogator asked me about diabetic retinopathy, a problem in the eyes caused by diabetes.  With some relief at the topic presented to me, I expounded at length all my hard-learnt knowledge about the condition.  I sighed and smiled as I finished.

“That’s obviously not your favourite subject” he said.  “Let’s move onto something else.”

One could wonder if professional examinations test the ability to withstand psychological abuse as much as anything else but, despite all that, I passed.  Thank goodness – although, in the event of failure, there is always the opportunity to go through the whole unpleasant process once more.  As one of my mentors put it, “There is no profit from passing the examination first time but every profit in having passed it at all.”  An afterthought: presumably the psychological robustness of those who, despite repeated failure, take the examination three or four times without giving up is statistically greater than those who pass it first time.  Somebody should do the research.

Teddy Bear’s Triumph Chapter 4 Post 3

I successfully applied for a senior house job in Sheffield, which provided three six-month periods of work, in cardiology, general medicine and gastroenterology.  I had to move from Oxford to Sheffield, of course, but they granted me single-room accommodation within the hospital for as long as I would like it, which, in the event, was not very……………….

………….……. I had never been to Sheffield before my interview, which was held in December.  I travelled there from my parents’ home in Manchester, over the Snake Pass, approaching Sheffield from its north side.  Although the M62 did exist, at that time a large proportion of lorry drivers had continued their earlier habit of using the Snake Pass to traverse the Pennines.  Since there was nowhere to overtake, my journey from Manchester to Sheffield, which is approximately thirty miles, took about four hours, during most of which time I reflected on how it must have felt to be part of a wild-west wagon train seeking fortune in the West (except that I was travelling east).

The Snake Pass was bathed in swirling fog, which added to the splendour of the occasion.  As I descended the mountain on its east side, a sign became gradually visible as swathes of cloud moved across its surface.  “City of Sheffield”, it said.  To say it was a surprise would be a great understatement.  Nothing looked less like the approach to a city.  We seemed more likely to be in the Middle-of-Nowhere or part of Transylvania.

A few miles further on, the reality of the city hit me head on because we were approaching through the steelworks, which were in such a flourishing state at that time that British Steel was losing an average of four thousand pounds per employee per year.  There was certainly a lot of activity but it looked thoroughly unpleasant.  The provision of entertainment by Sheffield City Council for visitors approaching from the North consisted largely of black smoke, bursts of flame and heavy machinery noise.  One wondered where the people lived.  It was only after having been in Sheffield for six months, when I ventured out of the hospital accommodation, that I realised that anybody of sufficient wealth lived in the South or West.  Until that discovery, which was actually quite pleasant, I had fully understood the claims of the local residents that Sheffield is such a marvellous city because it is so easy to get out of.

Apart from the steel works, my initial impressions of Sheffield may have been influenced by race memories from the Wars of the Roses, having moved from the fiefdom of my birth in the House of Lancaster to work in the House of York.  I must have changed my allegiance to the white rose at some point because I stayed in Sheffield to do my research degree and returned after a break as registrar and senior registrar to take up a consultancy in the steel town.  I also stopped going to Blackpool, although there may be other reasons for that.  I am surprised that I was not tried as a traitor because memories in those parts die hard.

Yorkshire people are the salt of the earth.  They are genuine, on the whole honest, straightforward (sometimes very) and have a good sense of humour.  Unfortunately, most of the consultants who work in that area do not originate from it and often do not share these qualities.  The three consultants for whom I worked as a senior house officer were, however, “of good character”, possibly because two came from Yorkshire originally and the other one was Scottish.

Ken Peacock was a wiry, balding man with a retained Yorkshire accent.  He loved cardiology.  He did not have the traditional air of a consultant, more of a teenage stamp collector whose exuberance at identifying a new stamp is understood by very few other people.  Cardiology, perhaps not surprisingly, involves listening to hearts.  Ken had raised the skill to its own art form and indeed was very good at detecting heart murmurs that nobody else could hear.  Well, that is what he said anyway.  We would stand round the bed, armed with stethoscopes, ready to attack the poor patient’s chest.  I took my turn.

“Diastolic component?” said Ken when I had finished.

“I can’t hear it, I’m afraid”, I replied.

The registrar took his turn.  “Diastolic component?” said Ken.

“I don’t think so”, said the registrar.

“Aye, it’s there.” Ken terminated the discussion.

It is surprising, how, if you spend most of the day listening to heart sounds, they can become something of an obsession.  I expect a similar experience is shared by a group of twitchers standing in a forest glade trying to identify some distant bird song.  Since the bird is rarely seen, there is little way of proving whose opinion on the matter is correct.

Listening to heart sounds was certainly an experience I gained in that SHO job.  I did an outpatient clinic with Ken.  He would see the new patients and I would see the follow-up patients.  Since virtually all the patients under follow-up were there because they had faulty heart valves, usually caused by rheumatic fever in childhood, an essential part of the follow-up was to listen to the heart to determine whether the murmurs had changed or new ones had been created.  In truth, since most of these patients came every six months, any one SHO would rarely have seen any of the patients previously.  It is difficult to describe a murmur in the clinical notes with sufficient specificity for someone else later to compare their findings with the previous ones, so the whole follow-up exercise, at least as far as listening to the heart was concerned, was of dubious value.  Of course, there were other reasons for follow-up, such as to detect any changes in heart rhythm or the presence of heart failure, but listening to heart sounds seemed to occupy the major part of the clinical exercise.  Allowing for two weeks of holiday during the six-month period, I estimate that I listened to thirty hearts per week for twenty-two weeks in that clinic alone, which amounts to six hundred and sixty hearts in total.  Maybe you can understand why it made such an impression on me.

Ken had a way with words.  On a Wednesday morning ward round, about half way through the job, we approached the bedside of John Townley who had been admitted for further investigation because he became easily breathless on exertion.  I presented the history and the findings on examination (because it was a specialist area, there was no houseman so I was still bottom of the pile).  Ken went through his usual routine of listening to the heart and identifying murmurs that nobody else could hear and glanced at the ECG rapidly as he passed it through his fingers.  Picking up the chest  X-ray, he moved closer to the bedside so that he could hold the X-ray against the light.  By now, he was about eighteen inches from the patient.  Jim took a sharp intake of breath after glancing at the X-ray.

“Oh what a terrible heart”, he exclaimed, almost gleefully.  “Three valves!”

Judging by Mr. Townley’s reaction, I am surprised we didn’t have to call the cardiac resuscitation team there and then.

The longer one spends dealing with acute or dangerous situations, the more the initial fear and anxiety subsides.  “You never get used to it” certainly doesn’t apply to medicine.  With sufficient experience, a real emergency, where urgent action is required, produces no more tension than dealing with a routine matter in an outpatient clinic.  The important thing is to decide what to do and to do it within the time you have available, which is not necessarily as quickly as possible.  Until there is realisation of this difference, the demeanour of an experienced consultant in dealing with an emergency can appear as benign indifference.

One of the routine weekly sessions in the Cardiology Unit was cardiac catheterisation, which was an investigation of the state of the heart valves or of the arteries that supply the muscles of the heart.  The procedure involved passing a catheter, a small tube, up one of the blood vessels in the arm or leg until it reached the heart.  X-ray dye was then injected into the chambers of the heart.  Valve leakage could be detected by visible escape of this dye from the heart chambers through valves that should have completely closed to prevent it.  Passage of a tube into the heart perhaps understandably irritates the heart and can cause it to beat in abnormal rhythms.  The more the heart is irritated, the more abnormal these rhythms become and the more likely is the heart to stop altogether.  Thus, a cardiology technician was on hand to monitor the heart rhythm during the catheterisation procedure.  She would call out the nature of any rhythm abnormality that was produced.  Withdrawal of the catheter back from the heart virtually always abolished the abnormal rhythms.  The test of steeliness of the nerves of the doctor was at which point in the development of a series of increasingly abnormal rhythms he would decide to withdraw.  Extrasystoles, isolated extra beats, would develop into runs of extrasystoles, a number of extra beats in sequence.  More heart irritation then produced ventricular tachycardia, which was a sign of very unstable heart function, to be followed only by ventricular fibrillation, which was loss of any organised electrical activity of the heart, resulting effectively in cardiac standstill.

Ken was the master of the cliffhanger.  Without flinching, whilst we were getting more and more hot under the collar, he would continue his investigation as the technician, with equal calmness of voice, spoke:

“Extras.”

“Extras running.”

“VT.”

“VF.”

Usually, Jim would stop at VT but I did see him allow progression to ventricular fibrillation before calmly moving everyone from the table and restoring electrical rhythm by electrical shock to the patient’s chest, using the cardiac defibrillator which was kept by the side in the event of such an emergency.  Normal heart rhythm restored, Ken then continued his investigation without a flinch of expression at any stage that anything untoward had happened.  At first I thought this behaviour was foolhardy but I learnt that medicine is essentially a hazardous business, both in investigation and in treatment, so the only way to gain maximum benefit is to know precisely how far one can go to improve matters without making the patient worse. Waiting for ventricular fibrillation may be going a bit over the top, though.

The responsibility given to junior doctors in those days was far greater than it is now, an experience that was at once both exhilarating and downright frightening.  It is surprising that there were not more catastrophes; perhaps there were but nobody noticed.

I was not long into the cardiology job before I was carrying out cardiac catheterisations myself.  On the whole, things went remarkably well until one day.  In order to access the vein to insert the catheter, it was necessary to perform a “cut down” which means making a small incision in the skin so that the vein can be seen.  A small nick is then made in the vein and the catheter is inserted through the hole.  On this particular day, all seemed to go well.  We were investigating the right side of the heart, which, on the whole, generated less in the way of abnormal heart rhythms than left heart catheterisation.  As the catheter entered the heart, I heard the technician’s words, familiar in another context, “Extras, extras running.”

I withdrew the catheter from the heart and, when the rhythm had settled back to normal, tried again.  The heart behaved rather better this time so I injected some X-ray dye.  The catheter was clearly in the left ventricle and not on the right side of the heart.  I stopped the procedure, sifted mentally through my not-so-encyclopaedic cardiological knowledge and concluded that the patient had a hole in the heart so the catheter had passed through the hole from the right side to the left.  My excitement at this discovery was dissipated after Jim arrived and informed me that I had inserted the catheter into an artery and not a vein; arteries are connected to the left side of the heart.  Ken was left to suture the hole in the artery because, unlike veins, the pressure in the artery is too high for the hole to close on its own.  The patient had a good pulse in that artery afterwards and suffered no ill effects.  Ken recovered from his initial reaction of anxiety bathed in an air of criticism.  I felt reassured at my decision not to become a surgeon.

Nothing I have experienced since has led me to believe that that decision was wrong.  Indeed, appropriate events have taken place at sufficient regularity to lead to the conclusion that I was undoubtedly right.  When I bought my first car, I decided that I would service it myself, in respect to all the friends of my father (but not my father himself) who serviced their own cars with apparently as much ease as any other routine day-to-day activity.  In fact, I think I did it all right but, by the time I had finished, the car was ready to be serviced again.  I never tried again.  That and a number of similar happenings led me to believe that I did not have a lot of practical ability at all.  I could manage painting and decorating but that was about it.  Later on, after harbouring years of feelings of inadequacy in this area, one of my mentors told me that he did what he was good at in order to earn the money to pay somebody else to do what they were good at.  Pretty good maxim, I thought.

As a junior doctor, you learn not only about the subject of medicine but also about the people with whom you work, other doctors, nurses, secretaries and patients.  This is, of course, typical of all jobs that work closely with people but the added feature of dealing with health and disease, and the precariousness of life, seems to make that involvement with the personalities of people more necessary and possibly deeper.  This is not always a good thing.  I have met a number of people with whom I’d rather not have a superficial relationship, let alone a deep one.  In my naivety, I once asked another of my mentors why some consultant had behaved in a particularly obnoxious manner.  “Harvey, there is a lot of psychopathy in medicine” was the reply.

My time in the SHO jobs seemed to go remarkably quickly, possibly because eighteen months isn’t very long to gain experience in three specialist subjects.  The general medicine and gastroenterology jobs I remember as a year of gradually mounting tension, culminating in the MRCP examination.  Fortunately, the serious business was punctuated by moments of levity.  Philip Parkin, my consultant on the general medicine job, spent the first hour of every ward round sitting in the sister’s office, drinking coffee and recounting stories, mostly of his army life, to his junior staff.  He certainly had a natural comic wit which was arguably superior to his skills in medicine.  He had a great sense of the absurd.  He conveyed effortlessly the pointlessness of the army initiation rite in which the young recruit is catapulted by four men down a polished dining table to crash head first into the fireplace at the end.  He was not a typical consultant.  Apart from his profuse curly black hair, corduroy trousers and Gipsy-like appearance, his beaten up, dirty Citroen 2CV would not have warmed him to most of the patients in private practice, for example.

I cannot tell you much about Donny McClaren, the gastroenterology consultant, because he was not often there.  He turned up for the ward rounds but his response to the history and other information conveyed to him by his junior staff was usually a rich Scottish “Aye” or, if he was really excited, “Ooh aye”.  He was in the last three years of the job before retirement, at which point he would receive a pension that was dependent upon his total earnings in the final three years of his job.  He did not supplement his NHS salary with any private practice but had regularly carried out domiciliary visits, which are examinations of patients in their home, at the request of the general practitioner.  Such a visit earns a fee.  Donny had grasped the nettle with a view to his pension income by carrying out as many domiciliary visits as he could manage in the last three years of his career so he was rarely in the hospital.

He was so successful in this venture that I suspect he placed one of those workmen’s advertisement boards outside each house he visited-

Donny McLaren

Domiciliaries ‘R’ Us

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