Regular Colonist: Bulgakov and the doctor's mess

Listened again via the website to the Bulgakov piece (see March 7th post) from his days as a country doctor, though given the total destruction of my day’s work this week I could have listened to it in the coffee room. Although there are few excuses for being found with tears streaming down your face - certainly not the day-time TV that is on in there permanently.

I’ve never been one for doctors’ messes. Never had time, and found the actual mess therein a sad indictment of our essential one-sidedness as people. We can compete as to who can get the needle in the difficult vein, who can keep their head under pressure – it is these aspects that seem to inspire competition – who can see the most patients in outpatients, not, who can speak the most gently, get the most heartfelt thankyous or loyal following. Our performance assessment will be difficult to achieve on these soft aspects. Yet we can’t pick up our plates and wash them up, clean the microwave after tipping some congealed canteen substance over it, put the butter back in the fridge. Perhaps it is the still-predominant public school element, those who haven’t got to where they are today by cleaning up after themselves. Perhaps I am out of date: now there are so many women in medicine do they clean up the mess? I think it unlikely. Surely women are just as likely to be the creators of grease stains on the sofas as the blokes and resentful about the assumption that they would be washing up cups for anyone except themselves. As well as working harder on the wards. I do not speak just my own mind here, but also quote my ex-boss who as a woman surgeon was completely convinced that women make better doctors, indeed better surgeons. “We are just as good on the technical side” she’d say, “but we can communicate without being hampered by arrogance”. Arguably as good a summary of gender differences as any. We’d listen to Radio 4 as we stayed late into the night saving some leg or other – with the essential break for the Archers. This is the kind of support in surgery women need. Not the politically correct admission that they might be as good as the men with the same training, but a bold assertion that they can take over a previously male stronghold and make it their own. It is a pity that Miss Ackroyd wasn’t here for a robust reply to Carol Black’s concerns about too many women in medicine. We had a Women In Surgical Training conference that sadly missed her fire, any fire on Monday... She is right of course, Prof Black, in asserting that the status is already falling as is the pay. This is society’s problem, however. Medicine’s challenge is to find the right dedicated doctors for the future. Not shoo them away when they have kids and get some more blokes in.

Back to Bulgakov. His depiction of the loneliness of his position nearly a hundred years ago: the availability of expert advice at some distance; his ego prevents him from accessing it. This situation is easily transferable to now: a hospital ward, at night. A junior doctor, in the first grade where they are left alone unsupported. Expert advice only a phone call away but exactly the same, the risk they might laugh at you or question your knowledge – disturbing a senior at 3am for something trivial, something you should know. Instead he makes an excuse and rushes out to consult the textbook – done that. He returns and is gently, mindful of his dignity, instructed by the experienced nurse: yes, been there too. Many an operation at night has the theatre nurse mutter comments in the guise of a conversation that actually constitute coded advice. Suggestions. My first appendix operations solo, I realised how many of the cues of what to do next I’d taken from my senior opposite number. I learnt to look up from my too-small hole in the belly, and see that Sister had some clips in her hand. “Clips” I’d order, straight-faced. With a tiny smile, she’d hand them over. I would later point this out to students of my own to the amusement of the theatre nurse present: “if Sister, who has been present at more of these operations than either you or I can imagine, is holding some scissors, then it is scissors you want next. Ok?”

I went through a stage of having to cover the on-call paediatrics in my hospital where I was the SHO in paediatric surgery. I had only had my medical student training in paediatrics: in a very advanced unit at a London teaching hospital where there were strange syndromes and odd, operated heartbeats and vicious nurses defending the poor children against gallumphing medical students. It was years before my own kids, and my knowledge was, as Bulgakov says, patchy, tenuous and bookish. All senior opinion was off-site. Except the senior opinion of the Sister in the small 2-bed casualty. Her practised way of encapsulating the problem over the phone, then when you arrived, a look to the sky if she disapproved of the parents and tutting if the child was seriously ill: these were my education in the banalities of minor paediatrics. This was GP call-out stuff in the main, for people whose GPs wouldn’t come, or they lived close and knew we were here. Rashes and temperatures, fast little heartbeats (a chart on the wall saying what was normal for the kid’s age. With the concerned parent staring at you – “you’re not very old” they’d said when you introduced yourself – all heartbeats sounded fast). Wheezy-sounding coughs, drawn up tummies. You’d make a guess, asking questions, attempting an examination all of which merely gave you time to consider what to do. The results of your enquires rarely made much sense as you knew nothing to pin the information gleaned onto. Then, you’d emerge from the curtains, the whole overheard by Sister (again, as Bulgakov notes, the approval registering for having gone about it in the right way) to whom you’d hazard a, “she might well be better off at home with some antibiotics”, being careful not to cut off your options – an about-turn of governmental proportions difficult to conceal in the staged conversation that ensued. Ask her directly what to do, not an option for most doctors, and you’d get, “well, You’re the doctor”. She’d make a move to the medicine box, or, tellingly, have the door open already: we’ve only got ampicillin. Or, “yes, yes, most of our doctors wouldn’t admit for a chest infection with no respiratory distress” she’d comment and you’d sigh, and write up your notes. You were in trouble if you managed to upset Sister, easily achieved. She was a prickly character. She could withdraw all erstwhile support and there you were, floundering, with a huge cold stethoscope, a screaming child and no idea about what to do next. Inevitably, “well, she’s the doctor” could be heard being muttered somewhere in the room.

In Bulgakov’s story, he allows himself to get flustered; his dread begins when he is first frantically called – recognise that: this night was too good to be true you think as you thump your way in to the hospital, hardly dressed. He forgets even the chloroform – too unsure to suggest it but rescued by the assured midwife who allows him to believe in himself for the patient’s benefit. Against the odds, there is an upbeat ending. He discovers, with the help of the experienced midwife, the true nature of knowledge. She has praised him, not excessively, for his “appearance of confidence” doing the procedure and he is initially unsure if she is being sarcastic. Yet still he says there is the wriggling worm of self-doubt. I, too, know that wriggling worm. I have also, as this doctor, gone back to the books when it is over. In the calm of his study, his panic dissipates as the cooling of his tea, he re-examines the text book that he’d left open on his desk, and it all makes sense in the light of his new experience. It is this that distinguishes the doctor from the student; and yet I would not, as the patient, want that doctor who has never done it before. Herein is the unmentionable problem in these days of supposed openness. To what extent training? What guinea pig? If we can’t practise how can we get experienced? It is true for all jobs, you need “at least 2 years of experience” and many are caught in this logical bind of needing experience for the job but a job for the experience. But if you are the patient, do you want to be the experience?