Just One More Question

by Niall Tubridy

  In this gloomy state, I recall two other patients I had seen the day before. A 78-year-old woman arrived nervously with her daughter. Her 83-year-old sister had Parkinson’s and she was worried that her own tremor heralded a similar fate for herself. Fortunately, hers was an intention tremor, worse with movements such as holding a cup of tea, rather than the resting tremor typical of Parkinson’s. She and her daughter shed a tear when I explained that she did not have her sister’s condition. A lovely moment among the horrors of bleak diagnoses that day.

  Another sad but beautiful moment comes back to me. Anneka is a Dutch woman who has been a patient of mine for over ten years with a variety of ailments – migraine, minor seizures, joint pains and dizzy spells. A retired postmistress, Anneka smokes heavily and her make-up evokes images of Bette Davis in Whatever Happened to Baby Jane?. We always get on well and I think she enjoys her visits, more to combat loneliness than to discuss her medical problems.

  Anneka had come in the previous day because her headaches had escalated in frequency and severity and the medication didn’t seem to be effective any more. As we discussed possible alternatives, the usually phlegmatic Anneka asked whether I felt that stress could be playing a role in her increasingly severe headaches – ‘explosions’ of pain that put her out of action for days on end. She went on to explain that she had been in love with a woman in her native Holland for over forty years. She was still alive and her family had put her in a nursing home as they had felt she was suffering from dementia. Anneka disagreed. She visited her as often as she could but the family had always suspected them of an affair and had resented poor Anneka all her life.

  The affair, in fact, had never been consummated and she welled up with regret about this. I asked her whether, at seventy-eight years of age, looking back now, she felt she should have taken the risk of the opprobrium of her own family, the woman’s family and society in general by going ahead with the affair.

  She paused and said, ‘Yes, I wish I had gone for it but now it is too late.’

  After a moment she said, ‘Besides, Sister Lotte, who loved me then and still loves me now, could never have faced the eternal shame she would have felt at breaking her religious vows.’

  Anneka’s headaches were a result of her unfulfilled love. At times, the simple humanity behind neurological symptoms would break your heart.

  26

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  PASSING THE BATON

  I have been teaching since I was a junior registrar but I still sometimes get nervous when about to teach a new class of students. However, once I pick up on the atmosphere of the lecture theatre or bedside teaching group, and gauge the students’ level of enthusiasm, if not immediately their aptitude, for neurology, I relax and begin to enjoy the sessions. In the past I probably relaxed too much, as one of my former bosses told me. I shudder now to think of the effects some more acerbic off-the-cuff comments might have had during my earlier teaching career, usually made when coming into the lecture theatre after a difficult morning in the outpatient clinic. I am also mindful that these days students can be offended by throwaway comments that in years past would have been viewed as a professor’s eccentricities. We are all learning to be more sensitive – and that is probably no harm.

  A lecturer’s mood and enthusiasm can be as fickle as those of the class they are trying to teach, but there is a real sense of satisfaction when you walk away from a class feeling that you have done a good job – and a sense of despondency when you don’t.

  Neurophobia, or fear of studying neurology, makes teaching the subject an additional challenge. This is a recognized condition that I have studied in recent years. Both medical students and non-neurology doctors find neurology difficult from their earliest years in medicine and can develop an attitude that it’s too difficult to even try overcoming their fear, or that there are too many unknowns for study to be rewarding. I understand this, of course, because I found it hard going for years, and as soon as I get cocky I come across a case that confounds me and where I get a kick in the backside and realize how tricky it must seem to doctors not seeing neurology patients every day.

  The fact that you cannot see or hear the brain – while you can listen to someone’s heartbeat, feel their pulse, observe the veins in their necks – is certainly a drawback for some. However, I find the unknowns enthralling. There is still so much about the brain we do not know that I cannot see how anyone could not be interested in this area of medicine, and I have always loved teaching students about how much fun neurology can be.

  We can take extraordinary pictures of the brain with MRI scans. We can perform electrical tests of the nerves and muscles throughout the body with neurophysiology. We can even test the fluid within which the brain and nerves are bathing with a lumbar puncture. These are vital ancillary tests of nerve and brain function. But for almost 150 years the neurological history and examination are still of the greatest importance when dealing with people with neurological problems. To my mind it is this beautifully human aspect of neurology that underpins the elegance of the subject.

  Neurology lends itself to teaching through a combination of science and theatre. But, for me, getting the patient’s story is central. I teach students the importance of approaching it like a detective, adopting a Sherlock Holmesian strategy to finding out the background history and making the connections. I explain the vital importance of tracing the patient’s movements and habits in the lead-up to the moment they discerned something was wrong. It is like a jigsaw, and even pieces that appear dull at the outset can be as important as any other piece when we come to see the whole picture. They should keep probing, Columbo-style, until they are satisfied that they have found out as much as possible – there is always ‘Just one more question …’

  I have always enjoyed watching the students’ reaction to seeing the neurology exam being performed. Explaining the mechanics of the brain and translating how we see, hear, walk and talk at a fairly basic level is wonderful fun and always thought-provoking. There may be somewhere between 150 and 200 students in the class. We have real neurology patients who have volunteered for the sessions come to the lecture theatre and I demonstrate the basics of each part of the examination. I stress that communication is everything, and physical communication in the form of mimicry is especially useful. Showing the patient the movements you wish to elicit is much more productive than merely asking them to perform each of the tasks involved. When I ask them to raise their eyebrows (‘as if surprised’), or frown (‘as if angry’), while doing so myself, they mirror my expressions much more easily than if I make the same requests with an expressionless face. (It can backfire when it becomes so clear to the patient that, for example, one reflex is behaving differently to another, and they quickly realize something may be truly amiss.)

  I try to involve the class as much as possible, which means that I bring up individual students to have a go at doing whatever I’ve demonstrated. I just pick randomly from the class. While this might seem cruel, and certainly anxiety-inducing, watching a peer do a good job inspires everyone else to raise their game. And if someone does make a hash of things, then everyone feels a bit better about themselves (except the poor soul who has been put on the spot – but even they will learn from their failure, I always hope). Patients who volunteer for these educational sessions are generally good sports and their insights into their conditions humanize things for students.

  Once students have the basics of taking a history and performing a competent neurology exam, we can move on to the far more captivating subject of the ways the nervous system can fail.

  In teaching junior doctors how to deal with everything that will be coming at them on a daily basis I try to zero in on the most fundamental aspect of being a doctor: their relationship with their patients. Surprisingly, that includes some thoughts on etiquette and presentation. I draw the analogy with First Dates. First impressions are crucial. You won’t make it to dessert if you eat with your mouth open, hold your utensi
ls like weapons or look like you got dressed in the dark. And many patients don’t think any differently about a doctor who looks unkempt or has poor manners.

  My opening comments to final-year medical students usually involve suggestions on bedside manners. Year on year this appears to be more necessary, as students encountering a patient for the first time will simply start barking instructions at them without any explanation as to who they are, what they are doing and why they are doing it. Maybe it is a lack of confidence, or even a dearth of social skills inspired by smartphone isolation, but now it is necessary to explain to twenty-somethings that they should introduce themselves to strangers by shaking hands and saying their name.

  Over the years I’ve heard people say that patients do not care how their doctors look as long as they are competent, but in my experience this is untrue. Patients see the seemingly superficial things and judge straight away; they’ve told me as much. In fact, my non-medical friends frequently comment on their doctor’s appearance before thinking to mention why they went to see the doctor. First dates indeed.

  And, of course, your shoes. Always with the shoes. As a medical student and younger doctor, what I wore was not very important when it came to spending whatever money I had. We were not paid much in those days and, living away from home, most of what we earned would immediately disappear on rent. If I am honest, I did not really think about it, as the priorities in those days were Tube fare and beer money. It was in London that a patient commented that I should learn how to knot a tie properly and perhaps consider polishing my cheap shoes. I was taken aback but started to notice that after each introduction most patients looked me in the eye, but immediately dropped their gaze to my shoes. And as the neurology exam starts with examining gait, naturally patients look down at your shoes when you are explaining what you would like them to do. The disappointment (or disgust) on their faces is rarely well disguised if the shoes are badly kept. (Mind you, a taste for nice shoes can go down badly if patients perceive them to be too expensive.)

  So I ask students to consider the impact that their appearance, demeanour and bearing will have on the vulnerable patients in front of them. I stress how quickly trust is lost on first impressions and how difficult it is to regain. I ask them to reflect on how their parents would look upon a young doctor who had barely bothered to disguise the previous night’s partying. With the female students I can be on tricky ground, as how can a fusty professor sound anything other than misogynistic (or, worse still, prurient) when suggesting that revealing clothing is best avoided? But I feel it is important to raise these awkward and unlikely topics. The more a patient is comfortable with how you come across and the more they buy into what you are trying to achieve for them, the more cooperative they will naturally be.

  Training in bedside manners has come a long way, even in my time. Hospital consultants were not altogether well regarded when I was growing up. Like that caricature of a hospital surgeon, Sir Lancelot Spratt, from the Doctor novels and films, a consultant was seen as one who took a lot of the credit without doing much of the work, flitting around the hospital wards trailed by teams of nurses, young doctors and medical students, pronouncing on the health, or otherwise, of the poor patients. He was the epitome of arrogance, more interested in having his own ego massaged than doing what was best for his patients. Like many others of my and the previous generation, I grew up believing that consultants were swaggering monsters with a God complex.

  Indeed, when we did ward rounds as students, there was still an element of this – as, of course, there still can be, depending on the personalities involved – and it seemed at times that patients were there for the consultants and senior registrars to make us look like the medical idiots we were then. When I eventually got to be a consultant I still would (and sometimes still do) give the students I feel are underperforming a hard time, but the patient is no longer a peripheral figure to be used for teaching purposes. We will have introduced ourselves properly and the patient will know, I hope, that we are all doing our best for them as a person.

  Every day we do a pre-ward-round review of all of the patients under our care to ensure we have the details of any recent test results correct, and to discuss how we think we can make each patient better as quickly and safely as possible. We discuss any sensitive issues that might arise, and how best to tell patients and their families any bad news. Once we are clear on each of our roles, we will visit with each patient at their bedside, and I will introduce myself and shake their hands to wish them good morning.

  So, though we do our utmost to ensure that patients don’t feel like teaching tools, we do still have to teach the medical students by the bedside when we can. Almost all patients kindly agree to this, though everyone understands when they don’t. Many patients say they love getting involved in the teaching, and tell me afterwards that, while listening to me explaining their medical issues to students, they learn a lot themselves. I always take note of this, because it means that, contrary to my best efforts, if some are getting more from me in ‘teaching mode’ rather than ‘doctor mode’, I need to do better on the communications front. I try to introduce each team member to the patients, so they know exactly who is listening to their personal information. (Strict confidentiality is a given, of course, but if a student comes across someone they know – say, a neighbour from home – they may opt out of the session.) If I ask a student to examine the patient – check a reflex, for example – I ask that they introduce themselves and explain what they have been asked to do in plain English, rather than in medical jargon.

  Looking back at my own early days, one of the great joys of being a young doctor was feeling a new-found sense of responsibility. By being in hospital for so many hours on each shift, we got to know our patients intimately. We felt a bit like ‘inmates’ ourselves, and would see close-up the subtle changes that would occur throughout the day in a hospital. Walking the wards late at night you became more aware of the noises that might keep you awake if you were a patient – the rattling trolleys, the frantic cardiac arrest calls, someone humming a tune as they walked along a corridor. Ireland is such a small country, and almost-without-fail long weekends on call in hospitals as a junior doctor brought this home to me; when chatting to patients and relatives you would make some connection between your family and friends and theirs.

  I recall delightful conversations with the elderly patients in my first job on a geriatric ward. They would tell their stories, not just as lists of medical problems to be solved, but as part of the arc of their lives as a whole. Hearing about their upbringings in a different era, and learning first-hand how unbelievably poor many Irish people were for so long, was a lesson in social history and quite an eye-opening experience. The patients brought the story of the country alive for me and I learned more from them than I had done in years of schooling. They seemed to revel in their tales of woe, but would do so with a smile. The late-night chats and realizing how much you were helping them was immensely satisfying. And they understood how young and green we were as doctors and made excuses on our behalf to the senior medics or surgeons when we couldn’t find their x-rays or forgot their blood results.

  As medical students and junior doctors we had a deep sense of camaraderie – that we were all in it together. We would go in on Saturday morning and not leave the hospital until Monday evening. After twenty-four hours we were paid half time and after forty-eight hours we were not paid at all. This is inconceivable to the junior doctors of today and, with the introduction of the European Working Time directive that limits the hours doctors are legally allowed to work, the team structure we were weaned on has become fractured. Less ridiculous hours is, of course, a good and humane thing, but I wonder if the loss of a sense of belonging has led to a sense of isolation for some of our young trainees.

  We all have our good days and our bad days at work, but a bad day as a young doctor might involve watching someone in terrible pain or seeing multiple people die. It is a terribly difficu
lt burden to bear alone and, when you finish your shorter shift after one such bad day and return to your flat to sleep, dark thoughts about your future in medicine must be difficult to deal with. When we had such bad days as young doctors, we rarely left the hospital but instead shared our tales of woe through chats in the doctors’ mess – often with older doctors who had been there, done that and lived to tell the tales, who were there to remind us that all was not so bleak. While young doctors’ hours and pay are better these days, the expectations of them emotionally are the same. Perhaps this is why many of them appear to feel somewhat disgruntled and unsupported.

  Most medical students start their careers with deep empathy for their patients, beginning with their diagnosis and down the sometimes long road of treatment, but in time a protective shell of cynicism can creep in. The long hours and late nights are very draining. The nonsensical calls to chart paracetamol in the middle of the night can harden a young doctor’s attitude. Couple this with the daily encounters with the depredations of disease and death and one has to develop a sense of detachment or risk becoming a complete wreck. (I travelled this road myself – I found myself a little cynical after a few years as a young doctor – but with a combination of experience and people close to me getting older, developing illnesses and relating their experiences, both good and bad, with doctors, my sense of empathy has been renewed.)

  I only left home to live with friends when I got paid after my first month as an intern. I was twenty-three years old. In my first few years as a doctor, I earned less than a thousand pounds a month while working anywhere from seventy to 100 hours each week. We lived in a world where career progress was slow and the money relatively meagre compared to the work you put in. Yet we were having the time of our lives and felt indestructible – we would manage to go to the nurses’ parties in the Mont Clare Hotel on a Monday night on a few hours’ sleep, having been in work since Saturday morning. I still had to study for yet more exams, and eventually got my Membership of the Royal College of Physicians, which meant I could go to the next stage of my career and start to train as a neurologist. I was twenty-six years old and started to move from hospital to hospital in Dublin. Every six months or so I would take up a new post, meet new friends and colleagues and learn about how each hospital worked. By the time I had got to know each new system I would have to move on again, an aspect of medical life that has not changed much for young doctors today. It may seem very unsettling but I found it tremendously exciting.