Just One More Question

by Niall Tubridy

  My dad was involved in administering electroconvulsive therapy many times, he told me. Although it could seem cruel and violent, he assured me it was a far more controlled procedure than it was depicted in the movies, and some of his patients who had suffered with intractable depression for years had only gained respite by receiving ECT.

  My father hated being asked about his work when out socially, in part I think because of how psychiatrists were perceived. Psychiatrists, he would say, instantly provoked fears in many that they might be analysing you even in everyday situations, so it must have been socially tricky at times. I know from some of my own interactions socially that some people think neurologists do the same thing, so I would be very surprised if psychiatrists did not still suffer the same stereotyping as my father even today. Then there was the stigma surrounding mental illness itself. How awkward it must have been socially in less open times when psychiatric illness and mental health in general were rather taboo subjects, seen as frailties of the mind (as they were), but also somehow the sufferer’s own fault.

  I have been lucky to have met many of my dad’s former patients, or relatives of his patients, who very kindly have spoken highly of him. They tell me tales of how he saved their lives, their parents’ lives or their marriages. I have met many of the doctors who trained under his supervision at one stage or another of their careers and, though hardly impartial, they tell me how much they learned from him and how much they admired his methods and the way he approached patients.

  It is always lovely to hear nice things about your father. Of course, I don’t hear from doctors who disagreed with how he went about things. It’s nicer this way, but it would be foolish to convince yourself that all was rosy throughout the career of any doctor – particularly if you’re trying to learn from it as a doctor yourself. I have met psychiatric in-patients who were treated by my father and his colleagues years before and still required treatment. Some, still sick, who realized that I was his son have vented about his shortcomings as a doctor. Even knowing how unwell they are it can be upsetting – to see them still unwell, knowing that my father must have done his best, and to be reminded that even our best efforts are not always enough.

  As I grow older I am more sensitive to the vagaries of the doctor–patient interaction and appreciate the joys of a successful consultation, one during which you feel that you and the patient have communicated well, and hopefully you have affected the patient’s life for the better. I also have had to accept the fact that no doctor can hope to get on well with all the people they encounter and with some there will never be a meeting of minds.

  9

  * * *

  ALL IN THE MIND?

  Jessica was a little late and somewhat flustered arriving into the Melbourne neurology clinic where I was working. Though she was Australian she reminded me of the English actor Helena Bonham Carter in her off beat mannerisms and vintage clothing. I met her only once but she certainly made an impression. She was thirty-two and had become fixated with the idea there was something wrong with her right hand – her dominant hand – and asked her GP to refer her to a neurologist.

  Once she appeared more settled she explained that the problem had evolved gradually. She liked to paint but had noticed that the strength in her right hand had diminished. Now and again when working at her easel she found it hard to reach the top of the large canvasses she worked with and had even taken to trying to paint with her left hand at times. Despite this deficit she had tried to ignore the problem but it had been getting progressively worse since the preceding December. That was more than six months earlier, so I asked why it had taken her so long to seek help. After a pause, and a fleeting glance to her left, she said she was not sure why but she just did not think it was anything serious.

  I made the usual inquiries about her overall health, lifestyle and previous medical problems but there was nothing revealing. I asked whether there was any family history of neurological problems like MS, Parkinson’s disease or motor neuron disease and she went quiet.

  ‘I don’t know,’ she whispered. ‘I haven’t seen my family for nearly six months.’

  At times like this I feel very intrusive and am never sure whether probing further into such family troubles will create more problems than solutions. I am very close to my family and struggle to understand the reasons why families fall apart and how people cope with the isolation from those who have known them best in their life. It is not uncommon, however, to see people like Jessica who have lost contact with parents and siblings, maybe for years, and sometimes they cannot even remember the original reasons for the rupture – or don’t want to tell me.

  I asked Jessica if she wanted to talk about it and she paused again. Her gaze appeared to flit once more to her left side before returning to look me in the eye.

  ‘No, Doctor, I would rather not go there.’

  I examined her carefully and could find nothing wrong. The tone, power and co-ordination of her right hand appeared normal. All of the reflexes were present on her right side and equal to those on her left. I checked her ability to sense touch and gentle pain but again, all was intact. In a young woman like Jessica a neurologist would almost always want to exclude multiple sclerosis but there was nothing to indicate such a diagnosis. I asked what she had googled before coming to see me.

  ‘I don’t use the internet, Doctor. Never took to it.’

  I found this astounding but strangely credible given her unusual affect during our conversation. For the third time I registered her looking to her left, in the direction of her left hand, which appeared to twitch intermittently as she gazed at it.

  ‘Jessica, can I ask you if there’s some reason you look towards your left from time to time?’

  She flinched.

  ‘I don’t know what you’re talking about. You’re reading too much into things.’

  ‘I wonder if you have some stress in your life at present. Sometimes – not always – when we can’t find the cause of a symptom, it can be a sign of stress.’

  Once again she looked towards her left hand, this time blushing slightly.

  ‘No, no. I’m not under any stress. Well, there’s the family situation, but I’ve made my peace with that.’

  I backed off; I was pushing her too hard. I said I would like to arrange some blood tests and an MRI, but reassured her that I had not found anything untoward and was just making sure I wasn’t missing anything.

  ‘How much will they cost?’ she asked.

  ‘Oh, this is free. This is what we pay our taxes for,’ I said.

  She looked towards her left hand, which she raised to her left ear, and mimicked someone talking. I watched, mesmerized, and waited for an explanation, but none was forthcoming.

  ‘I have to ask, Jessica, what is going on? What are you doing with your hand?’

  ‘I’m just asking it for advice as to whether or not I should go ahead with your tests.’

  She stood to put her jacket on and her hand rose to ‘speak’ to her again.

  ‘What do you mean, Jessica? Is your hand talking to you?’

  ‘No, Doctor, this’ – she raised her left hand once more – ‘is my angel.’

  I persuaded her to sit down and explain. She told me that for the last six months her left hand had taken on a life of its own and had become her guardian angel that advised her on all aspects of her life.

  She seemed perfectly sane in every other respect so I wondered how or why this odd behaviour had started. ‘Has anything happened in the last year to upset you?’

  She started to cry and caressed her left hand with her right. Her estranged father had turned up the previous Christmas Eve after many years abroad and there had been an almighty family row over the holiday period. Around New Year’s Eve she started to believe her left hand was talking to her and guiding her through the troubled period. Far from finding this weird she took great comfort in her new-found angel and, knowing she had ‘someone’ she could rely on, was actually less a
nxious. This had become a fixed delusion and was causing her to act strangely, but it was not doing her any harm.

  It did not take much on my part, other than holding up a mirror, for Jessica to see that the unresolved family feud had led to her current plight. She refused my offers to arrange counselling, and although she agreed to the tests I planned, she never turned up for the appointments. This happens more frequently than one might think, and I often find out later that people were afraid of what the tests might reveal.

  I didn’t see Jessica again before I left Melbourne but think of her from time to time and wonder what became of her. Do people like Jessica take a dislike to anyone who points out what is obviously a psychological problem? Can it be that when someone like Jessica is faced with the truth, problems such as hers gradually resolve themselves? Or perhaps she concluded she was content as she was and didn’t want any more interference. Who knows, but there is only so much one can do. Doctors can feel a sense of failure in cases like Jessica’s, but, when teaching medical students, I share Jessica’s story to point out our limitations.

  Debbie had had a similar problem when I met her in London in the late nineties. Her left hand had started to take on a life of its own one January. The difference between her and Jessica was that Debbie then started to have trouble walking as well and arrived at the clinic on crutches. She had a husband and two young children but came alone to her appointment. She had great family support, she assured me, and told me her family life was a very happy one.

  Incredibly friendly and apparently open and sincere, Debbie was instantly likeable. I was taken aback, however, when, with much encouragement to get her to move her arms and legs, I could not find a clear-cut neurological problem. I was pleasantly surprised for her, as my initial – wrong – impression when she struggled in the door was that this was not going to turn out well.

  I told her the good news, adding that in case I was wrong once more, I would look for the usual neurological suspects that can sometimes fool us. But I reassured her that I did not expect to find anything serious.

  Her mood turned instantly and her sunny demeanour was replaced by a glare.

  ‘How dare you say there is nothing wrong with me; what do you know anyway?’ she said.

  I was gobsmacked by this rapid change and tried to explain again that I was only glad for her that I had found nothing on my examination that might point to conditions like MS or MND but that I would be making doubly certain with the tests I had planned.

  Throughout this very uncomfortable exchange Debbie’s left hand had stopped rising in the air and it dawned on me (rather slowly, I admit) that this was what we describe as a functional neurological disorder. It was ‘real’ in that Debbie was displaying the symptoms she was presenting with, and that they originated in her brain, but there was nothing structurally wrong with her brain or nervous system. In times past we might have labelled Debbie’s symptoms as ‘psychosomatic’. We no longer do. The word is freighted with a level of judgement that we try to avoid. Frankly, it’s not our business to judge people – there may be good reasons for a patient presenting with neurological symptoms that aren’t real in the sense of arising from a genuine neurological problem. Instead, we try to find a way of helping them.

  Giving Debbie vague explanations for her symptoms was not going to satisfy her or indeed facilitate her recovery. So I tried a different approach and spoke optimistically about how a problem like this was treatable and how, in due course, and with physical and perhaps some cognitive behavioural therapy, she could expect a return to normality, including going back to work.

  ‘If you think I’ll ever be well enough to go back to work then you haven’t a clue what you’re doing,’ she shouted.

  She was only twenty-eight years of age and had not worked for five years because of her disability. She was living on benefits. Surely, I said, she’d feel much better by regaining her self-confidence and becoming an active member of society again? I was wrong for the third time in quick succession.

  ‘You can go fuck yourself, you prick!’ she said and stormed out of the room.

  I paused for a minute and took a few deep breaths to regain my composure. I stood to call the next patient and asked the clinic nurse to chase after Debbie as she had forgotten her crutches.

  10

  * * *

  SIGNING UP FOR MEDICINE AT SEVENTEEN

  It was only later in life that I truly considered how my father’s medical speciality might have influenced who he was. A kind and patient man, he didn’t have much time for academia and just spoke frankly to thousands of patients over his thirty or more years as a doctor. He was a great listener and always advised us to try to hold back from rushing to judge people. (I am not sure how successful that lesson was!) He was generally quiet and had a very droll, sometimes acerbic, sense of humour.

  Unlike his children, he had been a great sportsman. He played as a flanker on his school’s rugby team and won a senior cup medal in 1954 playing against a famous Belvedere team graced by Tony O’Reilly, who later played for Ireland and the Lions. Although Dad rarely mentioned it, his rugby friends from years previously would delight in regaling me with the stories of how our father stopped ‘O’Reilly’ winning a coveted Schools’ Cup medal. He played water polo to a high level, but we never heard of this until a few years later. He was a good sailor, but I never saw him near a boat. Most of his children turned out to be borderline hydrophobic. When I asked him about these pursuits he would just shrug and say ‘self-praise is no praise’.

  He attended our awful attempts at rugby, soccer, hockey and whatever was our sport du jour without complaint. He would stand on the sidelines of our little sporting lives, always smoking discreetly, regardless of the rain and wind. He encouraged our every transient interest in music (an old piano lasted about six months), art, genealogy and even orienteering at one point. Now I think how he must have worried as he saw young men and women at the same ages as his own children succumb to alcohol, drugs or, worse still, suicide.

  When I mentioned that I was thinking of applying to medical school he seemed pleased in his understated way.

  ‘Are you sure that is what you want?’ he asked. Detecting some reservation on his part, I asked him whether or not he thought it was a good idea.

  ‘It is a great thing to do,’ he said, ‘but it is a very long road.’

  I knew it meant six years in medical school before you were qualified, but I did not quite appreciate, until he explained the process to me, how many years after you were able to call yourself ‘Doctor’ it was until you actually felt like a proper doctor. He explained that the first post upon qualification was a year as an intern – the lowest rung on the ladder. Then you became a senior house officer for two or three years, in which time you experienced many aspects of medicine before considering a longer-term speciality. Once decided, you would spend five to ten years as a registrar training to be a consultant. During that latter time you would have to spend many years abroad, away from your friends and family, with few opportunities in those days to travel home (due to the expense of air travel and the hours that you would be working). None of this was enough to put me off.

  I had not considered medicine seriously until my latter years in school. I was a fairly bright child, I believe, but went off the rails a bit in my early and mid-teens. I started to hang out with slightly older kids in the local area and schoolwork quickly fell down my list of priorities as I pathetically tried to keep up with my socially more mature peer group. At around fourteen I started to drink and smoke. My schoolwork suffered as a result of my social proclivities, and I lost interest in many of the subjects we were studying, and in school in general. I liked history and Latin but had no particular penchant for chemistry and biology, and physics was completely alien to me. I was, and still am, pretty terrible at all things mathematical. I love things that appear logical and follow a defined path yet, paradoxically, could not grasp maths or physics. I worked very hard at the former so
as not to face what I felt was the failure of dropping to the lower-level maths class, but I was really not able for it. My parents paid for extra tuition and I did my best, but my studies in other subjects suffered as a result of the inordinate time I had to put in to try (and fail) to master algebra and trigonometry.

  I considered journalism, social work and law as alternative career options, but once I got my act together in my last two years at school I realized medicine was within my grasp. I also began to get the idea it was exactly what I wanted, but, fearful of not getting the points, I played down my ambitions in front of my friends and my family until my grades started to improve.

  It was around this time that my parents’ marriage came to an end. It was very upsetting for everyone, not least because of the social embarrassment that separated families suffered in early-1980s Ireland. It was still an unusual event in those years and, while undoubtedly the best thing for all concerned in the long run, it made us feel somewhat ‘other’ for a few years. As a result, my siblings and I are incredibly close and have all made our own ways fairly independently since our teenage years. It is remarkable now to reflect on how my parents, like so many of their generation, married and settled down so young. They were both very loving in their own ways, but they were such different personalities that, in hindsight, parting seemed inevitable.