I look from one to the other. Dr Garber has opened the folder in front of him and has already started to read from my CV. ‘… Graduated with honours in surgery as well as obstetrics and gynaecology. Tons of publications. Recent presentation at a national meeting. Strongest candidate at interview.’
‘Ah yes, the interview.’ This upbeat, merry voice is my own. ‘The things I was asked. One manager wanted me to list the seven pillars of Clinical Governance. Like it’s some kind of monument! Well, fortunately for me, I had a mnemonic. PIRATES. Patient and public involvement. Information and IT. Risk management. Audit. Training. Effectiveness and Staff management.’ I count them off on confident fingers. ‘I mean, can you imagine what the general public, what patients would think if they knew this is the kind of stuff doctors are being tested on, to see if they’re good enough to become hospital specialists!’
We all laugh. The four of us are smiling together.
‘Shall I tell you about my first abortion?’
‘No!’ says Dr Garber. He stands up from his chair, hand raised. He looks like someone trying to stop a high-speed train.
It’s the GP’s turn again.
‘How did you feel immediately after doing that first abortion?’
‘Fine.’
‘Fine?’
‘Yes.’
‘Not shaky? Or upset?’
‘No.’
‘Well, I suppose that makes sense. I mean, you must have had strong personal reasons for signing up to do terminations in the first place.’
‘I didn’t sign up.’
‘But I’m right in saying you didn’t exactly opt out either? You didn’t conscientiously object?’
‘No.’
‘So, you must have felt pretty strongly? Not to conscientiously object?’
‘Must I?’
‘Didn’t you?’
‘Yes.’
‘You did? Or you didn’t?’
‘I did. I do. I believe in abortion. I absolutely do.’
I can hear a tapping sound.
Perhaps the lullaby effect of a story will stop them interrupting me.
‘It was in the very early days of my gynae training, and my sister had invited me to stay. Only, when I got there, I saw there were others too. An unfamiliar car parked outside, a couple I’d never met before, just sitting down at the kitchen table as I came in with my bags. And a baby, in one of those wheelie things, pushing itself around the floor. My sister made everything right, though. She sat us all down, my brother-in-law brought out the tea, and soon the husband-guest, a man called Simon, was asking me about my journey.
‘Then Julia went to the kitchen and got one of her fantastic cakes. A lovely Victoria sponge, which was super-high, not miserable and flat the way mine always turn out. And we all stopped talking to admire the cake and Julia cut everyone a piece. Soon we were all sitting round with these slabs of cake in front of us and it was then that the wife said, “Your sister was telling us you’re training to be an obstetrician and gynaecologist. What a fascinating job. It must be so rewarding being present at all those births?”
‘And I agreed, but I felt cross too. Because it always annoys me when people think that childbirth is the most interesting part of the job we do. So I replied that I had always preferred the other side of the specialty, gynaecology.
‘My sister went to fetch more water for the tea and Simon enquired which area of gynaecology that was, the bit I was doing at that particular time. I said I was in the middle of a module on Contraception and Sexually Transmitted Diseases and I only had to start mentioning these phrases for the wife to start eating her cake in quite a specific, careful way. And then, looking at her husband, but asking me the question, she said, “Does that mean you sometimes refer women for abortions?”
‘This made me a bit wild. So I let her have it. I said, “It doesn’t work that way, you know. There isn’t just some person out there, separate from the rest of the world, to whom we can refer women with difficult problems. That’s not really what being a doctor is all about. That person is an obstetrician-gynaecologist. And helping women with unwanted pregnancies is part of our job, our duty. Not just those who have everything under control, but also the ones who are in a mess. Helping them end their pregnancies, if that’s what they need to do.”
‘And then, just as Julia came back into the room with the kettle, the woman turned her full face on me and said, “What? Do you mean to say you actually do abortions?” And I said “Yes”.’
I look at my judges for any small sign of support. Miss Mansfield rests the ball of her pen on her page. Dr Garber clears his throat.
‘Then my sister sat down next to me, and put her arm around me. And she was so understanding, you know,’ I say, looking directly at the three judges. ‘She told me how brave she thought I was, right in front of her guests,’ I tell my judges, not taking my eyes off them. ‘And do you know what I thought?’ I look at each doctor in front of me in turn. ‘I thought that there was no way I’d be able to explain to these people, who had probably already made their minds up, how I had come to do my first termination. That no one had ever given me the luxurious scope for outrage that I was expected to grant others. That the experience of being in an operating theatre doing these procedures was quite different to that of hearing oneself talk about it while eating Victoria sponge. That I would never be able to explain to them how complicated it is to be a doctor.’
I realise where the sound is coming from. It’s the young woman Vivien’s foot. She is tapping it against her chair.
There is the tiny beep of a digital alarm. Miss Mansfield reaches forward to where her watch sits on the desk in front of her and presses a gold button on its side. She has her own set of questions. None of them stick in my mind. All her enquiries seem to be directed at trying to get me to say that I have not had enough support from my seniors. That I was thrown in at the deep end too early. That Frederick and Mr Kapoor are to blame for what has happened.
Anger fills the room. The sound of it dances around me. The Occupational Health lady looks straight ahead. Her cheeks are aflame. I can hear her foot, still knocking against the leg of her chair, but much more loudly now. Her eyes are the prettiest violet. Garber and Mansfield face each other closely. Their words are like one sentence.
‘Just admit it, Miriam?’ he pokes his finger at her. ‘She lost faith!’
‘That’s ridiculous, Tim! You’re putting words in her mouth. It’s totally out of order!’
The hour passes in the blink of an eye. I leave the seminar room and go down the stairs, cross over the main corridor and continue. As I walk, I look up at the huge photos on the wall depicting important members of the hospital staff. The beaming paediatric consultant who never smiles in real life. The good-looking radiologist who taught us how to read chest X-rays at medical school. One of the newfangled nurse consultants, standing proudly next to her medical colleagues. The head chef of the hospital canteen, because we are all the same in this establishment, Joe Public, don’t you worry. We all stand shoulder to shoulder.
It is only when I reach the foyer outside the ITU and HDU that I remember what I have been told. My patient is finally getting better. This is why I have come here. So that I can be close to her. I want to be near where nurses are taking tubes out of her arms and mouth. I want to imagine the incremental improvements in her physiology, the tiny clinical freedoms, the gradual healing, the body’s forgiveness. I look around for somewhere to sit, but all the chairs are taken, and the thoroughfare is as busy as a supermarket. The only other place is the Relatives’ Room, a place where families usually congregate for bad news. Finding it empty, I let myself in.
More care is taken in this room than in most of the hospital waiting areas. There are upright chairs and low-slung chairs to suit all sorts: those who would rather brace against disaster and those who would collapse into it. Some of the plants are real and properly tended to, and the magazines are tidy. There is even a water machine. I help myse
lf to a drink and cross to the far side of the room.
Outside, the sky lies low over the hospital. It is as light as it’s going to get and still raining hard. Down at pavement level, people cluster under trees and cigarette shelters, peering up hopefully at the sky. I see garish colours in the misty wet and imagine the swishing of mackintosh sleeves as I watch the tops of umbrellas moving in the rain, obscuring the people holding them. I see faces in hoods, rain rictuses showing what they might look like in moments of extremity.
My thoughts turn to my patient. I try to recall something exact about her. I cast my mind back to the names on the board that fateful morning, but nothing comes to me. I remember sitting on the stool in the operating theatre, patients being wheeled in, one after another, pale legs raised. This pudendum shaved, that one not. I envisage the different feet. Dirty toes with fluff-packed nails. Foolish girls’ feet with nails in scarlet and coral. Mothers’ heels all hardened and flat.
I consider all the girls who have come to see me over the months in clinic. Their polite postures and tight little scripts. Each one with her own scant argument, just enough to earn a mark on the blue page, and no more. My pad of HSA1s, thick as a slab. I search for something more specific and the feeling of searching is not new to me. Girls swarm around my mind. Fragments of stories jostle for primacy, but they are mainly Frederick’s, always the most dramatic ones, those he told me from his time in Africa. The corpses he bagged up, babies halfway out. The girl brought in by her dad, her whole bowel in a plastic bag, cut out accidentally with a pair of scissors. I try intently to access something from my own clinical experience. Surely I can remember one woman or girl? There must be someone whose details stand out, someone whose circumstances I can individuate? But all that comes to me is a memory of myself.
I am in my flat and I am bleeding. The light is strange outside. It is mid-morning, but darkish, with fog all around and the empty shade of winter. I go to the loo to check on what is happening and a great brightness there alarms the dim day. I wonder if I should shout or call an ambulance.
I take the bus to the hospital. In the Emergency Room I am put in a cubicle and wait a long time. A nurse asks who I would like her to call, but there isn’t anyone. Finally a doctor comes and instructs me to let my legs fall apart, as if this is what women’s legs would naturally do if only we would let them; at least women like me, at least legs like these. Our dialogue shrinks further so that his remark is soon just the spinning of a speculum’s screw, my response the creaking of my underwired bra as I lie back to accommodate him. The doctor tells me I am having a miscarriage. He doesn’t bother to say sorry. He can see what a mess I am.
Suddenly the door to the Relatives’ Room opens and a woman strides in, talking loudly on a mobile phone. I move away from the window and pick up a magazine. I find a seat in the corner.
‘The operation? Four weeks ago today. Exactly.’
I look up. The woman has crossed to where I was standing before and is looking out of the window. She’s slim. She is wearing a dark-pink puffer vest with a grey jumper underneath.
‘No, Jennifer. That’s the thing I just don’t get. Not a soul. Well of course, someone must have. That’s right. But not me, nor her father, obviously. She didn’t even tell John.’
I study her intently now, this tall graceful lady. Is it possible that this is my patient’s mother? I pick out the North Face logo on her anorak. I try to establish what her daughter might look like. The woman takes her free hand from her pocket and rests it on the dirty windowsill. There are lines on the back of it and I notice she is shaking.
‘Yes, well, Anthony has done that already. It was pretty much the first thing he did do, actually. Although I’m not sure it’s right. Yes, well that’s how he does feel. It’s typical of him. But I don’t know, really. I suppose all I want to do is put all my energy into helping Emily.’
No wonder I have fallen apart. No wonder I have ended up poleaxed by the thought of the other living thing in my operating theatre, its image being drawn into focus on the ultrasound screen, its trivial stature less noticeable than the daintiness of its distinguishable human form, its posture so touching, its heart lighting up among all the grainy black and grey.
When I look up, the woman is gone. And in the silence she leaves behind, I understand something quite clearly. I have done much worse than not articulating the particularities of my own experience. I have been deaf to those of my patients.
WEEK FOUR
It isn’t steady hands that qualify the brilliant surgeon. A compassionate heart doesn’t distinguish the excellent GP from his ponderous colleague. Able psychiatrists aren’t mind-readers any more than talented dermatologists are born to read diseases from the maps of our skin. What a doctor needs, to be good in any specialty, is a quiet appetite for the truth. The physician’s gift is to sort sense from the patient’s crowded somatic experience, the surgeon’s challenge to detect the melody of disease in the body’s cacophonous score. And, after this, a doctor has to be able to articulate what they have discovered, persuade their team of the accuracy of the diagnosis, in order that a plan for treatment and cure can be arrived at.
As I travel on the train to my sister’s, for the last time before I receive the verdict of my Fitness-to-Practise Trial, all I can think of is my own failure, my inability to perform these most rudimentary therapeutic functions. I have not even started to understand my patient’s truths, and I have not been able to tell my own. As I hurtle towards the conclusion of my story, I wonder what kind of doctor I am, after all, and how I deserve to be judged.
There is no one in my carriage to distract me. It is the middle of the day. Normal people are at work. The fields and towns I pass are too familiar to breed new meanings. Is there any defence for how little I have gleaned from my abortion patients, for how bald the clinical discourse over which I have presided has been? Is it conceivable that I am not wholly responsible, that some stories are just too hard for people to tell? Do certain facts have to struggle to find the circumstances in which they can be spoken? Are there secrets so delicate that they seek a special audience? Is it too much to hope that there has been a degree of recompense, that if my patients had no real opportunity to talk to me – recounting the mere skeletons of stories, the bare bones required for an abortion’s purchase – each individual woman’s secret tale might have been whispered somewhere else, at length, endlessly and without shame into an understanding ear, in the generous company of a mother or friend, a lover or husband, or even hand-on-stomach to that small life she knew she could not manage to support?
And if each difficult story is just searching for the right occasion to be uttered, might this explain why, as I travel towards my sister, I feel gathering within me for the very first time the events of my own huge mistake, arranging themselves and becoming organised, gaining momentum and sense, as if all my attempts to explain myself have been no more than a rehearsal, all the comments I have made before my judges nothing more than a warming up for this purposeful burgeoning? Is that why I feel a great desire to shape the facts into something that might seem like a kind of harmony, at least when prepared for a dear sister’s ear? What then will I say to Julia? How do I truly remember that most terrible day, where all this started, which was dreadful from its very dawning?
The night before my ruin, I slept badly. Just before my alarm went off, I dreamed that it was already morning, and that I awoke in my bedroom and looked out of the window to find the courtyard and gardens jet black. There were black wolves pacing around, as if the stones themselves were coming alive. Some slipped into the building, and I could hear their nails clicking as they ascended the stairs and came into the corridor outside my flat, where several were already sniffing next to my door. I woke up shaken and threw open the window and made tea and sat in bed with it. It was restless weather. The air was gusty and damp, and the eaves of the building moaned. I felt afraid, all by myself in my room, and impatient to be on my way, to get into the clean, sile
nt space of my operating theatre, where I was better accustomed to keeping my feelings at bay.
I caught the bus in the lonely morning and no one got on or off, and the monstrous vehicle rolled and swayed over the bridge, faster than a bus should. Soon, I was stepping into the other world, out into the reek of fast food from the high street. People were everywhere, despite the early hour, crowding around the main entrance of the hospital. And that morning, I was aware that the accents around me were not those of my family and friends; when I did meet someone’s eye, I wanted to turn from them because they looked mad, or had an angry dog. The paving I turned my eyes down to was stained with all sorts of filth, with butts and gum and foul sputum. The only beauty was in the faraway sky which felt more distant there than it had at home. My heart felt sick at what my hands were about to do.
Inside the Day Surgery Unit, things were as usual. On one side of the high wooden reception counter were the baleful general public, waiting to check in. Pristine, entitled staff sat on the other. I noticed again the private apartheid I had been aware of for months now between me and all the other doctors. The frosty nod I got from the receptionist compared to the warm smile she gave the orthopaedic registrar coming through the door just after me, the assistance the nurses conspicuously withheld from me as I shuffled through the trolley of notes to find the patients whose consent I needed for that morning’s list.
Arriving at the whiteboard, I saw that two of my patients had cancelled so that there were only six cases for me to get through, all under ten weeks’ gestation. An easy morning, I thought just before I saw May, the anaesthetist, coming out from behind one of the curtains.
‘Looks like fate’s smiling on us today.’ She approached me, beaming at a row of nurses as she crossed the room before lowering her voice to add, ‘Only a few to do, and no one’s fat or tricky.’ Then she looked at my face more closely. ‘Hey, you don’t look too good. New man? Burning the candle at both ends?’
Dirty Work Page 11