John barely noticed the rain that soaked through his expensive shoes and made his cigarette smoulder. Lisa’s pink fur slippers soaked up the rain like sponges but her feet were warm enough. Anna stood more comfortably between them in brown suede boots, as they leaned over the railings in front of the Accident and Emergency department gazing blankly through the rain. Ambulances rolled in almost silently, lights flashing, sirens off. It was raining less heavily than it had during the day, but it made the darkness feel closer. They smoked in silence. Across the car park, they could see the glows from near the gates, where those inhaling more pungent substances huddled together, occasionally sharing their smokes with the security guards.
The rain tapped on the windows as lights pulsed from machines that pipped quietly in the night, controlling the drip of fluids in and data out of Sally’s arms. She looked peaceful now, so different from when her ambulance rushed her in this morning. John had watched helplessly, banished to the side-lines as paediatricians and anaesthetists worked their way through their protocols. Watching was unbearable, and not only because it was his own child being stabbed repeatedly with needles, masked, bound and gagged, blooded and drugged, which is of course the brutal reality of what happens when emergency care meets serious illness. Worse was watching the blundered cannulations, the repeated transgressions of aseptic technique, the delays in administering drugs, the failure to find the right piece of equipment, the delay in summoning the consultant, the arguments about whether to transfer her to another hospital. This was unbearable.
On one of the wards one of the nurses had left her evening medication round to help a distressed and demented patient, “Somebody’s stolen my slippers!” the old lady wailed and other patients called out to tell her to be quiet. The drug trolley was left open and unsupervised as together they looked under her bed. Nearby, they noticed a little pool of intravenous fluids dripping onto the floor. Lisa’s bed was empty. In the treatment room, the ward manager and senior sister argued in hushed, but heated voices about forty milligrams of morphine that had gone missing that afternoon.
Calls from patients were stacking up slowly in the out of hours GP co-op, located in an annex to the A&E department. By this time, most people had given up on finding a cure for their symptoms before Christmas day and were prepared to wait until at least after the turkey and mince pies. A late cancellation by another doctor whose daughter had been admitted to hospital meant that the night shift needed filling at just a few hours’ notice. Anna had volunteered with barely a thought. It paid well, but she didn’t need the money, she did it because they needed her. She got a faint glow of satisfaction when her manager called her straight back to express her gratitude, but she shrugged it off, she was only doing her job. The same feelings of satisfaction she used to get from grateful patients barely registered any more. She wondered why.
It was impossible to recollect clearly what had happened that morning. Sally had been feverish all night and had to be woken up. They were late for her ballet class and John had been irritable and impatient getting her ready. Of course he hadn’t performed a clinical examination, he was her dad. Like a hundred or more children he had seen at work that week he’d felt sure it was ‘just a virus’. Once, about a year ago, when her younger brother had burned himself, Sally had told her father to take him to the doctor. ‘But it’s ok, daddy’s a doctor’, he had said in his reassuring, doctorly voice. ‘No’ she replied firmly. ‘You’re not the doctor, you’re daddy’. He related this to his colleagues at the time and one by one they out-did each-other with tales of broken bones, metabolic disorders, and overwhelming infections that were left way beyond what they would expect or hope from their patients. He imagined how outraged Sally would be to hear them.
Lisa left her flat in the early hours of the Friday morning. She cannot remember quite what she had intended, but imagined that she’d gone in search of something else to drink or something to jump off. Until ten days before, she had managed to continue working without fault, as the senior clinician in her department. She noted with some satisfaction that in spite of drinking the best part of a bottle of gin a day for the last 2 months she still performed better than her colleagues. An invitation to apply for the post of clinical director, almost unheard of at her age, sat with a star on it among her emails to be dealt with. Drinking, in her mind was about testing boundaries, she liked messing with her head. Her mother had schizophrenia and coped remarkably well with it and was a successful geneticist, researching her own condition – what else? Lisa explored her mind in other ways, experimenting with hallucinogenic drugs in adolescence and at medical school and then, in the interests of trying to understand what her patients had to go through, tried all the different psychiatric drugs she was expected to prescribe for her patients.
Anna’s husband and kids would all be in bed by now. She had meant to call them, but didn’t think to stop and have a break until it was too late. They were pretty understanding really, they had to be with a doctor for a mum. She wondered whether other families were less forgiving, made their medical relatives feel guilty about the all the time they spent at work, the unsocial hours and unscheduled shifts. The kids had protested in their own way, when they scrawled with crayons across the calendar, ‘mum’s at work, mum’s at work, mum’s at work …’ She had tried to make it up to them by bringing presents home after spending last weekend at a conference, but they had taken the presents and ignored her. She felt cold as she thought about it. It wasn’t just the December rain.
By 6 years of age Sally was already showing precocious talents at whatever she, or more accurately, her parents, chose. John had always felt that he could have done a lot more with his life and didn’t want Sally to grow up, plagued by his regrets. None of his family had been to university and his parents had been incredibly proud, if a little bemused when he managed it. He chose medicine, a little half-heartedly, ‘to keep his options open’. At the time, he saw it as serving an apprenticeship and having a trade to fall back on, but what he really wanted was to play football, or the guitar. A medical degree was just supposed to be insurance, but gradually, medicine took over his life. John the centre-forward and Jonny the lead guitarist were subsumed by Doctor Davis the A&E consultant. He had recently lost interest in watching football or listening to music as the stars grew ever younger and reminded him of what was no longer possible.
Lisa’s childhood had a mixture of benign neglect or liberal laissez faire and she was naturally adventurous and talented. She found success wherever she applied herself and not infrequently in places where she didn’t try. She entered medicine because she thought it would be a challenge, but found her peers intellectually dull and unsophisticated with the exception of a clique who seemed destined for psychiatry. She had a natural affinity for her work, and an easy empathetic way with patients and staff, and progressed quickly in her academic and clinical roles. She was an obvious choice to run the sick doctors programme. She quickly became very close another psychiatrist with schizophrenia who she had for a long time admired. Their professional relationship was bound by the strictest confidences, but they shared a rebellious desire to test boundaries and experiment not only with medications but their roles.
Anna’s parents separated when she was twelve, just after her mother’s second breast cancer. She never forgave her father for abandoning them after everything they had been through, while her mother was in the depths of depression and undergoing palliative chemotherapy. She cared for her mother for the last year of her life and knew from then on that she was destined to be a doctor. She quickly became disillusioned by how impersonal and scientific medical education was, compared to her experiences with her mother and the doctor she wanted to be. She wanted to right the wrongs, to re-humanise care, to make doctors talk honestly with patients and families about death and dying, to admit when care was futile, not to abandon them at their time of need. She found her home in palliative care and general practice, where she had time to build up relationships with patients. By drawing on her own painful experiences she discovered her gifts for empathy and caring.
We have made virtues of independence and objectivity, though it is where lives intersect that medicine is practiced. We teach doctors about clinical depression but very little about human misery and we teach them how to treat cancer but next to nothing about how to deal with the fear of death. We train doctors to be scientist problem solvers, viscera-mechanics rather than holistic practitioners who will sooner or later discover that what ails the body also ails the soul.[i] In part this is because medicine has provided us with a taxonomy of suffering according to whether it can provide diagnostic proof, therapeutic intervention or profits. What falls outside is none of our business, in the widest sense of the word. We propagate a medical persona, individually and collectively internalised, that unlike our patients we are healthy, resilient, rational and indefatigable.[ii] We proudly display our passports for the kingdom of the healthy, because secretly, we believe that the kingdom of the sick is a punishment for weakness of the will, lack of stamina or moral torpitude.[iii] [iv] Little surprise then that for too many doctors, death is preferable to being seen to be vulnerable or weak.[v] Ours is a one-way mirror, designed to protect us from our own suffering and vulnerability, but allowing us to look right through it and see in others what we fear in ourselves.
As they turned to go back to the hospital, they caught sight of one-another for the first time. There was something familiar about the mixture of sadness and determination. The roots perhaps of their vocation.
The Bad Doctor: The Troubled Life and Times of Dr Iwan James. Brilliant comic book delving deep into the life of a GP.
[i] Kennedy I. Reith Lectures: 1980 Unmasking Medicine Lecture 2: The New Magicians
[ii] Zigmond D. Physician Heal Thyself: The Paradox of the Wounded Healer http://www.marco-learningsystems.com/pages/david-zigmond/physician-heal-thyself-3.htm accessed 28/02/2014
[iii] Sontag S. Illness as Metaphor and AIDS and its Metaphors. Penguin Books 1983
[iv] Wallace J. Mental Health and Stigma in the medical profession. Health (London) 2012 16: 3
[v] http://www.kevinmd.com/blog/2014/02/doctors-commit-suicide.html Accessed 28/03/2014