Practice Makes Perfect

by Rosemary Friedman

  “Let’s hope we’re not going to have to open you up again,” I said. “I think that you’ve had more than your fair share of hospitals.”

  Mrs Evans looked at me reproachfully as I removed the blanket.

  “Doctor,” she said, “I have never been inside a hospital in my life!”

  Of course it was Lulu’s fault for muddling up the notes, confusing Mrs Gwynneth with Mrs Myfanwy Evans, but it was my fault too because I had known them both for a great many years and should have been paying attention to what I was doing. I was so ashamed of myself I took it out on Lulu and she went home in tears.

  When Fred and Sylvia returned bubbling over with the purple grass-paper I was in a filthy temper. I had grown up with my patients and grown to love them, many of them at any rate. When they came to mean no more to me than notes on record cards I felt that something, somewhere, was wrong.

  “When will our wretched slum be ready?” I barked at Sylvia.

  “I told you, three months. And there’s no need to be like that.”

  “You told me two!” I shouted.

  “Well they’re having trouble with the Borough Surveyor. Something to do with the foundations.”

  “Well, if you don’t get us settled in the wretched place pretty quickly I’m not damned well moving at all!” I shouted. That started Sylvia off in tears, making two. I turned my attentions to Fred and was about to vent the rest of my spleen on him when the telephone rang.

  I looked at Fred and Fred looked at me.

  “You’re on duty, man.”

  “It so happens that you are. I was only doing you a favour while you and Sylvia…”

  “Not to worry, man,” Fred said gently, picking up the telephone, and making me feel ashamed of my churlish behaviour. “Not to worry.”

  He listened on the phone for what seemed to be an age, arousing my curiosity. Finally he made soothing sounds and said that he’d be over right away.

  “Jimmy Roberts,” he said when he’d replaced the receiver. “He’s been screaming non-stop since this morning and Mrs Roberts is, as they say, ‘at her wits’ end’.”

  “I’m not surprised,” I said. “Her husband died last night. Squadron-Leader Roberts, you remember him, Sylvia, coronary thrombosis; no, you probably don’t, you were fast asleep.”

  “I did hear you mumble something when you came back.”

  “I was shattered; forty-three next birthday. I’ll go and see Jimmy, Fred, you can get back to your grass-paper.”

  “As you say, man.”

  “It’s probably more in my line, anyway.”

  “OK, Mr Freud.”

  Mrs Roberts was indeed, as Fred had said, “at her wits’ end”.

  “Jimmy has got completely out of control and I just can’t stand it,” she said. “He’s kept up this racket non-stop since this morning. If I talk to him he’s just abusive. He was always such a good boy.”

  “He’s bound to be upset, Mrs Roberts.”

  “It’s not just that he’s upset. He’s acting so oddly. Like a stranger, won’t let me near him. I can’t take any more, Doctor, otherwise I wouldn’t have called you out so late.”

  As we climbed the stairs I could hear the animal-like screams coming from Jimmy’s room.

  He was sitting bolt upright on his bed, white with exhaustion, yelling. It was hard to believe one small boy could create such a volume of sound.

  “The doctor’s here,” Mrs Roberts said.

  There was no let-up in the noise and he did not acknowledge our presence.

  “Jimmy, please! The doctor’s come specially to see you.”

  “I don’t want to see the doctor.” His voice was hoarse.

  “He’s come to find out what’s the matter with you.”

  “There’s nothing the matter with me!”

  My eardrums were almost shattered.

  “He seems very disturbed,” I said, “about the death of his father.”

  “He’s not dead!” Jimmy screamed. “He’s not! He’s not!”

  Mrs Roberts sat on the bed and tried to put her arm round him, but he cringed away. “Jimmy darling, I’ve been trying to explain to you since this morning. I had to tell him,” she said to me.

  “She’s lying!” Jimmy screamed, trying to disappear into the corner.

  “I wish I was.” Mrs Roberts was now in tears herself.

  “Your mother’s telling the truth, Jimmy,” I said. “I know it’s hard for you to understand but Mummy is telling you the truth.”

  The volume of screams increased. “She’s lying! She’s lying!” He drew a great sobbing breath. “My Daddy isn’t dead. He isn’t! He isn’t!”

  “I can’t take any more,” Mrs Roberts said. “He’s been accusing me of lying all day. He’s had nothing to eat and has scarcely stopped screaming.”

  I looked round the room with its model railway, which I knew Squadron-Leader Roberts had got as much enjoyment from as his son, its books, games and total evidence of small boy.

  “Mrs Roberts,” I said quietly, “has Jimmy seen his father?”

  “How do you mean?”

  “Since his death.”

  She looked horrified. “Of course not. He’s only seven years old, Doctor!”

  “I know. I was wondering whether it might not be the best thing. He accused you of lying, you see, because he doesn’t really believe that his father is dead. He doesn’t want to believe it.”

  “I couldn’t do it.”

  “I’ll do it for you.”

  “No.”

  “We can’t let him carry on like this.”

  “I thought perhaps a sedative…”

  “It wouldn’t really solve Jimmy’s problem.”

  She thought for a while.

  “Look,” I said, “just leave this to me! Jimmy,” I said, firmly taking the tightly clenched fist. “I want you to come with me.”

  Still screaming I led him to his father’s bedroom. At the door we stopped. As if at a signal, he became quiet. I led him into the room and up to the bed on which lay his father’s body.

  He did not avert his eyes.

  “Daddy,” he said defiantly. “Daddy?”

  He waited for an answer and when there was none very slowly raised his hand and touched his father’s face. Just once more he said: “Daddy,” but this time it was not a question.

  Utter silence bathed the macabre scene for what seemed an age, then Jimmy tore his hand out of mine and rushed out onto the landing. I left the room, closing the door gently. Outside, to my great and utter relief, I found Jimmy in his mother’s arms, weeping. Real tears were rolling down his tired little face. He clung to her as if he would never let her go.

  “He’s come back,” Mrs Roberts said, drying his eyes and her own with her handkerchief.

  “He’ll be all right now. This is the natural reaction of a child. Soon he’ll quieten. You can give him something to eat and put him to bed. Try not to leave him alone.”

  “Thank you so much, Doctor… It would never have occurred to me…”

  “Please,” I said, “stay there with Jimmy. I’ll let myself out.”

  In the car I realised what immense satisfaction I had obtained from dealing with the problem of Jimmy Roberts along psychological lines and thinking of my slip-up with Mrs Evans wondered whether, after so many years, I wasn’t getting the slightest bit weary of general practice.

  Then I decided that it was not so much tired perhaps as stale. I was fed up with patients who took advantage of the Health Service; of those who demanded home visits when they could have come to the surgery; of the “while you’re here” people whose house you called at expecting to deal with one patient and were presented with four; of looking down throats and examining rashes and syringing ears; of climbing too many stairs in too many blocks of flats; of trying to find non-existent house numbers in the dark; of patients who suffered from verbal diarrhoea and never seemed to get to the point; of those who had to have instructions repeated four or five times be
fore they would let you go; of people who turned up clutching reports of “miracle cures” torn from the Reader’s Digest and became affronted if you could not perform them.

  I knew that nothing had really changed. The patients were good and bad, considerate and inconsiderate as they always had been. Their complaints were no more and no less trivial than before. I guessed it was my introduction to psychiatry that was responsible for altering the perspective in which I saw my work.

  It was an introduction too, for as I could now see, the paradox existed that the branch of medicine which occupied more of the time of the general practitioner than any other should be the one for which he was worse trained. In my time psychiatry had been a minor part of the undergraduate curriculum, and I had, through my sessions with Toby, been made aware of my deficiencies in knowledge in this speciality, particularly as they concerned general practice.

  The scheme for psychiatric history-taking taught in medical school was quite inappropriate to conditions in present-day general practice. In hospital one could allow a leisurely half-hour for each patient; in the surgery he was lucky if he got five minutes.

  The general practitioner’s task was hard in one way because many patients resented even the slightest hint that their problems might be emotional in origin, yet easier in another, because he had the advantage over the hospital consultant in knowing at first hand the family and its social background.

  It was rare, in general practice, for a patient to come complaining of “depression”. I had learned now, however, to look in a different light at those who felt “anaemic and run-down”, had been “fighting off flu”, thought their symptoms must be due to “the change” or suffered from “low blood-pressure”. I had a better understanding of the causes of lassitude and fatigue, no longer dismissed lightly women who left the housework undone, men their businesses unattended. I viewed with greater perception the constant demands for iron tablets, vitamins, tonics, or any other placebo I cared to suggest. I learned with surprise, for I had not previously considered the matter, that many patients were ashamed of their “feelings”. That unless questioned directly, they did not like to admit that they had become increasingly “touchy” and that the most trivial upsets seemed intolerable or minor obstacles insuperable. Each thought he was the only one in the world to fly off the handle at the office or resent his children’s demands for attention. They considered that to discuss their “emotions” with the doctor was a sign of weakness. Of all this, and much more, Toby had made me aware.

  From him I learned that the old saying “people who talk about suicide never do it” was untrue; that no one mentioned their sexual difficulties spontaneously; that one should avoid such glib and pointless advice as “have another baby” or “get a part-time job”. Week by week I cultivated a skill neglected during my training; the ability to tolerate the patient’s symptoms without feeling that each one should automatically elicit an investigation or a pill; to make sure the patient was asked to return for another consultation without leaving the onus to do so upon him.

  My weekly session at St Mark’s had opened for me new vistas in general practice and perhaps made me a little impatient with those who made what seemed trivial and impertinent demands upon my time.

  Eight

  The following day, at the hospital, Toby put me straight. No complaint, he said, was either trivial or impertinent. The “jittery” mother who called upon me the moment her child sneezed, was quite possibly suffering from a basic mood disorder herself. The middle-aged business man with his constantly recurring “trivial” sore throat may well admit, treated correctly, to a morbid and irrational fear of cancer and be greatly in need of help. Where else was one able to help these people better than in the daily round of general practice? They certainly could receive no assistance in hospital out-patients, as they never presented themselves there. I had only to look at Jimmy Roberts and the way in which, because of my recently acquired insight, I had been able to deal in the best possible way with his problem, to realise that psychiatric knowledge enhanced, rather than diminished the needs of general practice.

  This homily was delivered in the gentleman’s lavatory which, ludicrously enough, seemed to be the place where I was learning most of my psychiatry. The reason for this as I ultimately discovered, was the enlarged state of Toby’s prostate gland, necessitating frequent trips down the corridor on which he insisted I accompany him.

  I was just beginning to get used to Toby and the Department of Psychological Medicine at Mark’s. Amongst the staff, from the Professor down, were some of the country’s finest brains, yet the cleverer they were the more naïve they liked to appear. This applied in particular to Tommy, whom I had never heard talk about anything except roses, unless it happened to be manure; and to a lesser extent to Toby, who was forever getting involved on the telephone with his wife in lengthy conversations concerning the expected visits of the plumber or the man about the double glazing, and heated arguments over whether the Dutch blinds in the garden should be cleaned this summer or next. The behaviour and general standard of conversation of the entire department seemed, at times, in keeping with the lowest intellectual grade.

  I had often wondered whom they all reminded me of and, on the day of Toby’s pep-talk on general practice, I suddenly realised it was Faraday, which was in itself a coincidence. Faraday and I had been friends through medical school. He had been best man at my wedding and had ultimately married my cousin Caroline, who had whipped him off to the States where he was now a highly esteemed Professor of Neurology, and seemed to spend a large amount of his time flitting from one capital city to another reading papers, quotations from which I would come across from time to time in the medical journals, or even the national press. We did not communicate, except by telegram when we had something of importance to say. Caroline and Sylvia exchanged long flimsy air-letters, comparing children and their lives as doctors’ wives. Faraday was the cleverest fellow I knew; you would pass him by as nondescript in the street, and put him down as shoe-salesman at a social gathering. I should long ago have learned that outward appearances were deceptive and that, as Sylvia said, if you had it inside you didn’t need to put it in the shop window.

  I suppose you could have called it extra-sensory perception, a thing in which I did not believe, because when I got home from the hospital Faraday was there. Well, not exactly there, but on the other end of the telephone. As usual he was larking about. The waiting-room was packed, there was no sign of Fred, or Lulu, and Sylvia was out. In the house I answered the telephone in my “ask for a visit if you dare voice”:

  A nasal whine said: “Is that the doctor?”

  I grunted.

  “This is Mr Child, of Child’s ’Ill, me child’s ill.”

  It took me a moment, but only one. “Faraday.”

  “Bingo!”

  “Where are you?”

  “In the surgery.”

  “Whose surgery?”

  “Yours.”

  “What the hell do you mean?”

  “When I arrived there wasn’t a soul and the waiting-room was bursting at the seams,” Faraday said. “I’ve already seen a hammer toe and diverticulosis. Who do you send them to these days?”

  He simply never changed.

  “Well, carry on with the good work,” I said. “I’m just going to get washed. I don’t know what can have happened to Fred.”

  “Fred?”

  “My partner. You haven’t met him. He’s supposed to be doing the surgery. As soon as he arrives we must have a long natter. You must stay for dinner.”

  “Oh, I am.”

  “You am what?”

  “Staying for dinner. As a matter of fact you’ll find Caroline in the kitchen cooking it.”

  Caroline hadn’t changed either. She was in the kitchen a little plumper and a great deal blonder, standing up on the larder steps and hurling what seemed to be most of our store of provisions into the waste bin.

  “Rubbish! Rubbish! Rubbish! Po
ison!” Clang! Clang! Clonk!

  “Caroline. What exactly are you doing?”

  She sat down on the top of the steps.

  “Honey, do you still have all your teeth?”

  It seemed an odd greeting from a relative one hadn’t seen for goodness knows how many years.

  I bared them for her benefit.

  “You do surprise me; you really do. Did you know you were eating garbage? Pure unadulterated garbage?”

  I rescued a tin of artichoke hearts from the waste-bin.

  “Expensive garbage.” I remembered how she had always accused Sylvia of trying to poison me.

  She read from the label on a can: “…colouring matter, sodium-glutanate, sulphur dioxide, edible starch, soda, vegetable gum, partial glycerol esters, sodium sulphate, sodium phosphate…”

  “Caroline,” I said. “Do you realise that you haven’t even said hallo?”

  “Do you really think that social niceties are more important than your health, which is simply a matter of eating correctly? If you really do, why…”

  “Caroline, darling, I have known for years that Sylvia has been trying to poison me. If I hadn’t I would need only to glance at those endless reams of flimsy paper on which you list no less than twice a month the perils of pesticides, the criminality of chemicals, and the atrocities perpetrated by artificial anythings. But, as you see, I still have all my teeth, well nearly all – but that was Peter’s rugby ball, all my health and nearly all my strength. This, despite the fact that I still sleep on feather pillows, breathe in all that nasty old upholstery dust, and subsist, as you have discovered, on a diet of poison.”

  “You may laugh,” Caroline said, retrieving some wisps of hair which had straggled round her face during her attack on the larder.

  “I am not laughing.”

  “You always did.”

  “Perhaps I have matured.”

  She threw herself off the steps and into my arms.

  “Honey, you haven’t matured one bit. You still look like a harassed GP, have no sense of humour, and I adore you. Why didn’t you visit with us?”

  I extricated myself from her embrace. “You are now in England. Doctors are poor white trash. The Atlantic ocean is a not only wide, but expensive piece of water. We do not have that kind of money.”