Friday, September 22, 2006

Layers of Unreality

A week in which, having had the previous week off for the medical humanities conference, suddenly every patient interaction became fraught with meaning. I’m not sure this is efficient, but it was interesting.
It reminded me of past moments where layers of unreality had been exposed.

The first time, after 2 years of the medical sciences course I spent a year doing English. A rote-learning sponge waiting to be told what to think next, initially I turned up hopefully to every lecture, all 2 of them every week. Insecure, unjustified in any opinion, I was by turns fascinated by the texts and appalled that I was supposed to construct a 15000 dissertation out of them. Then I arrived at medical school after eventual conversion, a mere year later, into a fully-fledged English student, black polo-neck and all. Immediately I was an undercover agent about to lift the lid on medicine from the inside and report back to the real world. Medical training as they’d never imagined it to be. They, the normal people, the non-medics. Of course, it has been done to death since then. Though less of the waiting around for non-existent registrars in canteens and the jockeying for position, by turns hiding at the back and jostling to the front. More of the dramatic stuff of medical student life – admittedly few and far between – call it televisual artistic licence.

Now I recognise these shifts in perception and can carry on through them with hardly a jolt, even enjoy the moment. I waited outside my house tonight for twenty seconds to do just that, as I’d walked home from work thinking like a doctor, being 90% doctor with the facts of the rest of my life attached, as on a CV. Then outside I had to readjust to being a mother, which is more than 90%, it is total. To your kids, whatever else you do as a parent, it is just a name, something to remember like the fact you support Arsenal. One they might get muddled up. One kid knew at 2 that I was a surgeon. However, at 4, after a term of school, he was convinced mummy was a nurse.

Things have changed, though. When our second patient, an anxious Scots bloke, was shown in he chatted happily to the middle aged Indian guy who’d let him in while I sat at the computer finishing off the endless clicking that one patient entails in various programmes that don’t communicate with each other. Eventually I rose and went to introduce myself and he did a double-take. The nurse was quicker than me: “oh, she is the doctor. I am a nurse”. I hoped for a laugh when I said how we’d all swopped genders these days but you could see his discomfort as he readjusted. Perhaps it will be less easy for 4 year olds in the future . 70% of graduates are women and most are sensible enough to head straight into general practice – most of the doctors the 4 year olds see will be women.

At work there was the Rastafarian, manly as they come, resisting any analgesia for his colonoscopy but then, “get this ting outta my body!” In fact there were a few issues of withdrawn consent – a lady from the ward whose veins had given up and gone home. She yelled and the boss said, oh we are nearly there and, “you don’t want to have to come back do you?” and she yelled some more and we all got uncomfortable. But we were nearly round. She was unsedated, so in the end, her absolute instruction to stop was un-ignorable. I’ve always felt that dilemma with the objecting sedated patient given that they will probably not remember objecting. When do you take a single mumbled, “stop” and when does the protest constitute withdrawn consent? When the list is over-running?

There was a doctor-patient, who had to be jolly as he was one of us, then couldn’t help but show pain. Letting the side down. Of course without question we got the boss to do it. “The least we can do”. The NHS insurance plan, unwritten, that as a doctor (mind, it depends on your grade..) you’ll get business class treatment at least. From the doctors. I suspect that this is reversed for example by midwives – there was a malice in the way a certain midwife treated me in labour that I’m sure was exacerbated by the “Doctor” someone had written without my knowledge on my card. I insisted on having the Registrar for my tear. It may not have been sewn up any neater, but I exerted the right of my profession - to be treated by one who knew at least as much as me.
Of course, there are times when you’d rather have the junior doctor than the boss – for example running your cardiac arrest (the boss is usually out of date unless he’s an ITU specialist). And I tried very hard to avoid doctors altogether for my next labour – but also kept quiet about being medical.
Lawyers are also granted special treatment. Often the boss will take over. Extra careful consenting. Special mention of every complication, with exaggerated risks. Their mental health may suffer, but we can’t be too careful. They may, like their medical fellow patients get over-investigated and medicalised, iatrogenically injured, but we can’t be too careful...

Then there was the young man who was an Orthodox Jew. Unthinking, I went to shake hands. Both with him and then, forgetting, with his father later. He wouldn’t. I didn’t dare ask what they thought about a non-Jewish woman doing an invasive colonic procedure but wish I could know. There wasn't a means to find out. You could argue also that by asking, I’d have changed the question. As discussed at the conference – medicine as experienced by patients, of all cultures, religions and professions has a different history to the received history of medicine. And yet, the process of retrieving that patient-led experience changes it, especially, I fear, if the asking is done by a member of the profession.

We had the experience but missed the meaning. That is what medicine was all about, my undercover report seemed to conclude. And they aren’t worried, the trainers. The ideal is not to think about it too closely. In fact the consultants who trained me would fit better with
had too much experience but deliberately (dis)miss the meaning

1 comment:

aj said...

How interesting. This whole heirarchical behind-the-scenes system is taken for granted by most doctors. Your request for the registrar reminds me of Gawanade's refusal to let his daughter be treated by the trainee in his book Complications - something I felt to be disappointing at the time of reading, but have come to appreciate as opportunity; why not get the best if one can.
'Letting the side down' is another intriguing concept, linked to your de-doctoring outside the front door. We all need to hang the white coat up, take off the ID and put on a dodgy jacket to make us a person again before we leave work. How can we ever expect to tolerate medical treatment otherwise?