by Adam Kay
Tuesday, 3 February 2009
Last day at work before moving on to our next postings. It always feels odd to leave a job where you’ve watched lives begin and end, spent more hours than at your own house, seen the ward clerk more than your partner, and have your departure go all but unacknowledged – but I’ve hardened to it by now. There’s such an extraordinary turnover of junior doctors that I understand why there’s no great fanfare. As a particularly venomous matron once hissed at us, ‘You are temporary visitors at my permanent place of work.’
I’ve never once had a goodbye card, let alone a present. Until today, when I found a package in my pigeonhole from Mr Lockhart. A card to say thank you and goodbye, and a brand new Montblanc pen.
7
Registrar – Post Three
Eventually there comes a point where you have to decide what kind of doctor to be. Not the technical stuff, like whether you’re into urology or neurology, but the more important matter of your bedside manner. Your stage persona evolves throughout your training but you generally settle on a way of dealing with patients a couple of years in, and carry it through into your consultant career. Are you smiley, charming and positive? Quiet, contemplative and scientific? I presume it’s the same decision policemen make when they decide if they’re good cop or bad cop (or racist cop).
I went for a ‘straight to the point’ vibe – no nonsense, no small talk, let’s deal with the matter in hand, a bit of sarcasm thrown into the mix. Two reasons, really. It was already my personality, so there wasn’t too much acting involved, plus it saves an awful lot of your day if you don’t do the five-minute preamble about the weather, their job and their journey every fucking time. It sets you up as a bit distant but I don’t think that’s such a bad thing; I didn’t really want patients trying to add me on Facebook or asking what colour they should paint their downstairs bog.
The conventional teaching is that patients want doctors to ask open questions (‘Tell me about your concerns . . .’), then give them a variety of treatment options, from conservative to medical to surgical, so the patient can make their own decisions. Terms like ‘choice’ sound good in theory – we all like to feel we are masters of our own destinies – but have you ever been in a canteen queue where there are more than a couple of mains? People dither, they change their minds, they look for affirmation from friends. Is the haddock nice? How about the shepherd’s pie? I don’t really know what I fancy. And all the while, your chips are getting cold. Sometimes, it’s best to cut to the chase and remove any room for doubt.
On labour ward especially, I found that patients gained confidence from their doctors advocating a single management plan – you need the patient to be calm and trust you implicitly with their life and the life of their baby. Likewise, in clinic I saved countless patients delays to effective treatment by not proffering a specials board of options that are almost certainly of no benefit, just so I can say there’s been patient choice. Instead I’ve offered my expert opinion; the patient’s choice is whether or not to take it. It’s what I’d personally want if I saw a doctor myself, or even if I took my car to the garage.
But there’s no hiding from the fact that a direct approach makes you a less ‘nice’ doctor. Being trusted is much more important than being liked, but it’s good to have the whole set, so I decided in my third post as a registrar – now working in a huge teaching hospital – to warm up my bedside manner. It wasn’t totally spontaneous, I’ll admit; someone had complained about me. It was about my clinical performance rather than my behaviour, but it so totally floored me that I realized I needed to do everything in my power to never attract a complaint again, and if that involved hairdresser-style chit-chat and an elbow-to-elbow smile then so be it.
A letter arrived at home out of the blue from the hospital I’d worked at two years previously, letting me know a patient I had operated on was suing me for medical negligence. As it happens, I wasn’t negligent – bladder injury occurs in 1:200 caesareans, and she was informed of this risk pre-operatively on the consent form she signed. I’d like to think the risk of me injuring your bladder is considerably less than 1:200, as I only did it once and had many more than 200 other opportunities to do so. I felt terrible at the time it happened, but knew it had been managed well – I spotted what I’d done immediately, the urologists came to repair it straight away, and although it must have been distressing for the patient, ultimately it resulted in nothing more than a slightly delayed discharge home. I also thought it was managed well with her afterwards: I was apologetic, honest and humble, which in this case didn’t require any acting at all. The last thing you want to do to a patient is actually give them one of the complications you warn them about. First, do no harm; it’s right at the top of the job description. But, shit happens, and on that occasion it happened to her.
Messrs Cunt, Cuntsome and Cuntiest – solicitors of the ambulance-pursuing ‘no win, no fee’ persuasion – took a different view. According to their expert opinion, which seemed to have been honed from skim-reading a book called Law: Just Throw the Fucking Lot at Them and See Who Gets Back Up Again, the trust was negligent, I carried out the operation well below the standard reasonably expected of me, I greatly extended the suffering of the claimant and I delayed her opportunity to bond with her newborn child.
Unfortunately, I wasn’t able to counter sue for the hours needlessly spent going through old medical records, taking meetings with lawyers and defence unions, or the damage inflicted on my relationship by eroding the precious little time we spent together, nor the cost of the Red Bulls that kept me awake on night shifts after sleepless days of report-writing. Or the suffering I felt – the anxiety and guilt mounted onto an already stressful working life, the unfairness of being accused of being terrible at my job, the fear that maybe I was terrible at my job. I always tried my absolute hardest for every patient I saw and it was like a dagger through my heart for anyone to suggest otherwise.
The patient almost certainly had no idea how sad and exhausting the process would be for me – her lawyer no doubt smoothed down his moustache, put on his best concerned face and told her it was worth a roll of the dice in case it resulted in a nice payout* – and he was right, the hospital settled out of court, as they generally do. Maybe it’s just part of the gradual Americanization of the health service, that it necessarily becomes more litigious. Or maybe the patient was one of those joyless types who sues half the people she meets: the bus driver who doesn’t say good morning; the waiter who forgets her side of fries; me again for writing about all this. Whatever was going on behind the scenes, it left me at my lowest ebb as a registrar – asking myself why I bothered in the first place if now even the patients had it in for me. I seriously considered jacking it all in, something that had never occurred to me before. But I didn’t. I decided I would scrabble desperately around for a positive to take from it, which was to do my very best to protect myself from any future letters on legal headed notepaper.
‘Good morning!’ beamed Adam 2.0 in a typically over-running antenatal clinic.
‘You taking the piss, mate?’ said the patient’s husband. And so my revamp lasted two days.
* It would never be the doctor ending up personally out of pocket in a situation like this. The hospital will foot the bill, or a medical defence organization in the case of GPs. There can sometimes be a criminal case too if it’s considered gross negligence – and this doesn’t just apply to doctors. In 2016, an optometrist working at Boots was jailed for manslaughter for missing a symptom in a twelve-year-old child who subsequently died. A complaint to the GMC can run in tandem with any legal complaint, jeopardizing your registration and ability to practise.
Friday, 6 February 2009
Patient HJ needs an emergency caesarean section for failure to progress in labour. This has not come as a surprise. When I met her on admission, she presented me with her nine-page birth plan, in full colour and laminated. The whale song that would be playing on her laptop (I don’t re
call the exact age and breed of the whale, but I’m pretty sure it was documented to that level of detail), the aromatherapy oils that would be used, an introduction to the hypnotherapy techniques she would be employing, a request for the midwife to say ‘surges’ rather than ‘contractions’. The whole thing was doomed from the start – having a birth plan always strikes me as akin to having a ‘what I want the weather to be’ plan or a ‘winning the lottery’ plan. Two centuries of obstetricians have found no way of predicting the course of a labour, but a certain denomination of floaty-dressed mother seems to think she can manage it easily.
Needless to say, HJ’s birth plan has gone right up the fuck. Hypnotherapy has given way to gas and air has given way to an epidural. The midwife tells me the patient snapped at her husband to ‘turn that bullshit off’ when he was fiddling with the volume on the whale grunts. She’s been stuck at 5 cm dilatation for the best part of six hours despite Syntocinon.* We’ve ‘given it a couple more hours’ twice now, so I explain baby isn’t going to come out vaginally and I’m not prepared to wait until it inevitably becomes distressed and there’s a huge emergency. We’re going to need to perform a caesarean section. As expected, this doesn’t go down particularly well. ‘Come on!’ she says. ‘There must be a third way!’
I’m loath to court a PALS† complaint from a patient who wants their birth to be blogpost-perfect and has somehow been let down by nature. I’ve had a complaint in the past from a patient who I refused to allow to have candles burning while she laboured. ‘I don’t think it’s such an unreasonable request,’ she wrote. About having naked flames right next to oxygen tanks.
This patient’s got ‘strongly worded email’ written all over her, so I cover myself by asking the consultant to pop by and have a quick chat with her. Luckily, Mr Cadogan is on duty – he’s fatherly, charming and soothing, and he smells expensive, which has posh women flocking to the private ward he’d much rather be on. He soon has HJ consented for theatre. He even offers to do the section himself, to quiet mutterings of derision and amazement from the other staff. No one here can remember the last time he delivered a baby for free. Perhaps golf’s been rained off?
He suggests to the patient that he performs something called a ‘natural caesarean’ – it’s the first time I’ve heard of such a thing. The theatre lights are dimmed, classical music plays and baby is allowed to slowly emerge from the tummy while both parents watch. It’s a gimmick, and no doubt attracts a huge premium as part of his Platinum Package or whatever, but HJ laps it up. It’s the first time she’s looked remotely happy all day. With Mr Cadogan out of the room, HJ asks the midwife what she thinks about ‘natural caesareans’. ‘If that guy was operating on me,’ the midwife replies, ‘I’d want the lights turned up as high as they go.’
* Syntocinon (synthetic oxytocin) is an intravenous drug that increases contractions and speeds up a labour. You’re meant to progress by a centimetre of dilatation every hour or two, and if that’s not happening despite Syntocinon then it’s caesarean time.
† PALS (Patient Advice and Liaison Services) are the hospital’s complaints department. They take ‘the customer is always right’ to bizarre new heights and no matter how trivial the complaint would gladly have doctors turn up at patients’ houses carrying a bouquet of flowers and wearing a hair shirt.
Saturday, 7 February 2009
Missed the first half of Les Mis thanks to a tricky caesarean at twenty-nine weeks,* and didn’t have the fuckingest clue what was going on in the second half. (Especially as the goodie, Jean Valjean, and the baddie, Javert, essentially have the same name.)
Debriefing with Ron and the others in the pub afterwards, watching the first half didn’t seem to have helped anyone else understand it either.
* Caesarean sections are much more difficult for premature babies. The lower segment, which you normally cut through at full term, doesn’t properly form until around thirty-two weeks. This means you have to go through a much thicker part of the uterus, making it a harder and bloodier procedure.
Sunday, 8 February 2009
Simon called to say he’d cut his wrists last night after a fight with his new girlfriend and ended up in hospital for a bunch of stitches. He’s back home now and doing OK, with psychiatry follow-up arranged.
He asked if I was angry with him and I said of course I wasn’t. I was actually extremely angry – that he’d done it, that he hadn’t called me first so I could attempt to talk him down; surely he owed me that after the hours of time I’ve given him? I felt guilty that I hadn’t done enough – that I should have helped him better, or seen it coming and stopped it. And then I felt guilty about being so angry with him.
We chatted for an hour or so and I reminded him he can call me any time, day or night. But we’ve had this chat so often in the last three years, and it’s miserable to think that we’re no further forward than when he posted that first cry for help.
Actually, that’s probably the wrong way of looking at it. You don’t cure depression, the same way you don’t cure asthma; you manage it. I’m the inhaler he’s decided to go with and I should be pleased he’s gone this long without an attack.
Tuesday, 17 February 2009
The emergency buzzer goes and it’s a slightly tricky situation to restore calm in. As well as the usual dozen people buzzing around, there’s dust and rubble everywhere, and panic as a result. If this were an episode of Casualty, there’d be half an ambulance smashed into the room with us, but no. The midwife has pulled the emergency cord so hard she’s taken down most of the ceiling.
Thursday, 19 February 2009
It’s a great shame our child protection duties* don’t extend to vetoing some of the terrible names parents saddle their unfortunate babies with. This morning I delivered little baby Sayton – pronounced Satan, as in King of the Underworld. It’s hard to believe he’ll get through his school career unbullied, and yet we merrily wave him off on that journey. (Or maybe he’s actually the devil and I should have just shoved him back in.)
At lunch, fierce discussion with my colleague Katie as to whether my run-in with baby Sayton is better or worse than one she delivered called LeSanya, pronounced Lasagne, as in Lasagne. We regularly compare horror stories, like we’re playing Top Trumps: Obstetrics.
She tells me she once pulled out a baby girl called Clive, though I point out we’ve got a Princess Michael, so that’s not particularly impressive. Oliver says that where he was born, in Iceland, names must be picked from a specific list, from which it’s illegal to deviate. Doesn’t sound like the worst idea.
* All doctors have a duty, enshrined in their GMC code, to protect children and young people from abuse and neglect by acting on any concerns they have.
Wednesday, 4 March 2009
It shouldn’t be a notable event when I manage to leave labour ward on time, but today I do, and have a long-arranged dinner with Grandma in Teddington. She leans over after starters, licks her finger and wipes a dot of food off my cheek. As she licks her finger again, I realize slightly too late that it was a patient’s vaginal blood. I decide not to mention it.
Saturday, 7 March 2009
‘Doctor Adam! You delivered my baby!’ squeals the woman behind the cheese counter at Sainsbury’s. I have no recollection of her whatsoever, but her story seems to check out – that is, after all, my name and occupation. I ask about ‘the little one’, as obviously I have no memory of the baby’s gender. He’s doing well. She asks me ridiculously specific questions relating to the vagina-side small talk I had with her a year ago: how I got on with building the shed, if Costco stayed open until 8 p.m. on Thursdays like I’d hoped. I feel slightly guilty about the colossal mismatch in impressions we made on each other. But then again, I guess it was one of the most important moments of her life, and for me she may well have been delivery number six that day. It’s a peek into what it must be like to be a celebrity, a fan asking you if you remember a meet-and-greet after a concert ten years ago.
‘I
’ll put it through as Cheddar,’ she whispers to me as she weighs my goat’s cheese – it’ll save me a couple of quid and will therefore be one of the biggest perks of the job I’ve ever had. I smile at her.
‘That’s not Cheddar, Rose,’ announces her supervisor as he stalks past, and my bonus evaporates.
Monday, 30 March 2009
I’ve just printed off a scan of their baby for some parents and am wiping the ultrasound jelly off mum, when dad asks if I can take another picture from a different angle, saying, ‘I’m just not sure I can put this one up on Facebook.’ My eyebrows are en route to my hairline at these life-chronicling, self-obsessed social media attention-seekers when I take a closer look at the photo. I see what he means: it very much appears that the fetus is wanking.
Friday, 3 April 2009
Having a drink with Ron – we’re talking about his job and how he’s decided it’s ‘time to move on’. I sometimes think about the idea of moving on myself, but it’s a slightly alien concept when I only have one possible employer in the country. He offers to set me up with his recruitment consultant and tells me he’s sure I’ve got plenty of transferrable skills.
I hear this a lot from non-medics, but I don’t really buy it. The feeling is that doctors are expert problem-solvers, who pull together a constellation of symptoms to deduce a unique diagnosis. The reality is we’re more Dr Nick than Dr House. We learn to recognize a limited set of specific problems from patterns we’ve seen before – like a two-year-old who can point and say ‘cat’ and ‘duck’, but would struggle to identify a breeze block or a chaise longue. I strongly suspect I wouldn’t last long as a management consultant, applying my problem-solving skills to a failing branch of La Senza.
‘You should absolutely be on six figures by now,’ says Ron, texting me the contact details of his recruiter. I tell him I’ll get in touch with her, but I’m not sure I want to. I’m not convinced she’ll want me either when I outline my core competency: pulling babies and Kinder Eggs out of vaginas.
