Tuesday, 14 December 2010

Wise Old Dog

To say that people go to their doctor when they are ill is to make simplistic a vastly complex phenomenon. People go to their doctors for all sorts of reasons, but primarily they go with a concern that may or may not fit the doctor’s view of a thing that is “medical”.  A difficulty – even a danger – can arise when the doctor construes a presentation that has no origins in clinical disease as an illness. Sometimes indeed doctor and patient collude together in attributing “symptoms” to disease and then defining an illness that is not present. However it may suit both patient and doctor that they do so. The doctor may be anxious to press on and finish his surgery. The patient may actually want or need an illness for one reason or another. So the truth, perverse though it may seem, is that people may go to their doctor not only to have an illness diagnosed and treated, but conversely to be “given” a disease. But the patient may be exposed to risk in such an outcome, in terms of potentially hazardous investigations or medications that may cause side effects.

            One may sympathise with a person who sees “illness” as the only way of opting out of intolerable life or work situations. Perhaps less so with those who are out to gain clear advantage over their fellows through being afforded the special status that accrues from being ill. This reality has been recognised throughout history. Robert Burns illustrated it famously in his poem The Twa Dugs, an imagined conversation between two mutts from very different backgrounds:

The first I'll name, they ca'd him Caesar,
Was keepit for His Honor's pleasure:
His hair, his size, his mouth, his lugs,
Shew'd he was nane o' Scotland's dogs;
But whalpit some place far abroad,
Whare sailors gang to fish for cod.

And …

The tither was a ploughman's collie-
A rhyming, ranting, raving billie,
Wha for his friend an' comrade had him,
And in freak had Luath ca'd him,
After some dog in Highland Sang,
Was made lang syne,-Lord knows how lang.

            Anyway – this is what well bred Caesar had to say to rough and ready Luath about the monied, idle classes:

It's true, they need na starve or sweat,
Thro' winter's cauld, or simmer's heat:
They've nae sair wark to craze their banes,
An' fill auld age wi' grips an' granes:
But human bodies are sic fools,
For a' their colleges an' schools,
That when nae real ills perplex them,
They make enow themsel's to vex them;
An' aye the less they hae to sturt them,
In like proportion, less will hurt them.

            Do you see what it is that the sagacious Caesar is conveyingto his bemused companion? Essentially that hypochondriasis is a middle class phenomenon. In Burns’s time the poor had to contend with ill health and early death as a matter of course, while the wealthy might “need” illness as a way out of the boredom that afflicted them. In a more affluent society it might be assumed that the phenomenon has become prevalent, and indeed it is the experience of many doctors in primary care that this is the case.

            Such symptom complexes so constructed are sometimes referred to as “syndromes”. And indeed one definition of a syndrome is essentially that of a collection of symptoms. Strictly speaking, in a scientific or medical sense, the symptoms are often, but not always, a combination of symptoms and clinical signs, as is the case, for example, in Cushing’s Syndrome or Down Syndrome. These are indisputable physical entities. But there are others where symptoms are less specific (but often dramatic), not generally supported by hard physical signs and where there are no investigations that can support the existence of a physiological or pathological process.

            Curiously, too, these “syndromes” are the cause of much debate, not to say acrimony, within the medical profession, and huge drives to promote them without it. They are the subject of campaigns whose supporters are possessed of an almost religious zeal and energy. “Non-believers”, particularly in the medical profession, may find themselves vilified, even the recipients of threats. It is a brave doctor who will publicly state a view that holds that these things have no existence other than in the mind. And probably unwise too – for doctors above all else should be open minded (this is not the same as being credulous). For it is always unkind for a doctor to be dismissive of what his or her patient puts to them.

            Nevertheless, no doctor can afford to be dismissive of her or his scientific training either. As scientists, doctors ought to deal with facts and their practice should be based on facts. Not theories. Not unfounded beliefs. And not, of course, on lies or distortions put about for the purpose of dishonest advantage of one sort or another – either for the “sufferer” or for those unscrupulous pedlars and practioners of fringe medicine and quack remedies who do so well out of the vulnerable, the frightened or the foolish.

Sunday, 5 December 2010

A View of Two Sculptures

A little while back we were visiting our elder daughter and her two small children in Essex. I took the opportunity to drive up to Suffolk, primarily to make a long overdue visit to my parents’ grave, and then to see Maggi Hambling’s sculpture “Scallop” on the beach just north of the seaside town of Aldeburgh.
            I’ve known Aldeburgh for many years. My parents bought a holiday bungalow in Knodishall, a nearby village, not long after the end of World War II. We went there for weekends and longer summer holidays. My association with the town and the county ended more or less at the time of my father’s death in 1971. I return very infrequently now.
            A rather strange place is Albeburgh. The past few centuries have seen most of what was evidently a large town and port eaten away by coastal erosion. It rests up against a bleak shingle beach, a beach now more or less clean but which in my day was heavily contaminated by oil discharged by shipping traffic in the North Sea. But the houses ... now the houses, some of them, have a prettiness about them. Even some charm and character, quaintness and querkiness. See for yourself on any of  web sites designed to attract visitors. And it is not short of visitors, certainly in the summer months. And it is not short of people who have come to visit and then decided to stay there, usually to retire there I should say. And they are an odd lot indeed. Conservative, staid? Yes, but that is to put it mildly. The biggest problem for the crusty old colonel brigade is in fact Aldeburgh’s most famous son: that legendary English composer Benjamin Britten. He lies in his grave in the churchyard there, under a movingly simple headstone, next to his gay partner Peter Pears whose grave is similarly marked. A couple whose combined talent was complimentary and awesome. Yet I am left wondering to what extent it is actually appreciated by so many of those who have also made Aldeburgh a place to come to die. No doubt some do. But the others ...
            Perhaps this is best considered in the context of what was, until Maggi made her mark, probably the best known sculpture in the town. I don’t  know who made it, but I do know that it was – is – a memorial to a local GP’s dog. It squats by the children’s boating pond to one side of the Moot Hall and is called, would you believe it, “Snooks”. He and his master must have died a long time ago, because he was squatting there when I was a very little boy indeed. And if the townspeople hold it in the regard that they clearly do, then it is easy to understand why what Maggi has created on their wretched beach has vexed them so.
            I hear those voices that will not be drowned. Says it all, really

Friday, 3 December 2010

First Blog. The day after my 64th birthday

I opened my blog account on my 64th birthday. You see, I am a medical doctor – a general practitioner - at the tail end of my career, and due, fairly imminently, to “hang up the stethoscope” for good.

          30 years working full time in a “challenging” location in south east London has left me with amassed memories. Of people, situations, elation, sadness, success and failure. It may be that these pages will act as a host to some of these, and my reflections upon them.

          I find myself thinking again why it is that people become doctors in the first place. And it is in this context that I believe medicine may find the reason for some of its disappointments and dilemmas. The criterion – often the sole criterion – through which applicants get admitted to medical school is that of academic achievement. OK – so it must be of a sufficient level to enable the medical student to survive the four to five years of demanding application and study, and the years of postgraduate training in the chosen specialist field thereafter. But much is said about the idealism and philanthropic motives that cause young men and women to want to become doctors. Yet this is too often an Achilles heel, a source of ultimately frustrated ambition and disappointment. A “caring” soul is often keenly sensitive, too sensitive, perhaps, to survive the harsh reality and realisation that the power of doctors to make a real difference in peoples’ lives can be very limited indeed.

          Looking back on what my patients said and wrote about me when I left my London practice, it seemed that what most of them valued in their doctor was the ability to listen to them, and to treat them with courtesy. This is something quite different from the concept of the “caring” doctor. I have seen too many young doctors traumatised through simply “caring” too much. Some had their careers effectively destroyed by the tendency. A few broke down under the strain. Some even took their own lives.

          For me, courtesy was the backbone of my mode of practice. I made a point of being rather formally dressed, of greeting my patients – unless they were much younger than I – by their title and surname. Standing up, opening doors. That some construed that as “caring” did not matter in most instances. I may have been pretty consistently polite, but I lost no sleep over any of them.

          My reasons for going in to medicine, then? Job security (less guaranteed these days), adequate remuneration, and a certain status. Mind – I never admitted as much to those I “cared” for, but my own view is that they made me a safe and reliable doctor.