Dirty Work

by Gabriel Weston

  I open the swing doors and enter the foyer of the music hall. They have the same heft as the doors to the Day Surgery Unit. Here, though, those humans who look at me don’t do so with suspicion or barely shrouded distaste. The glances I get are from a couple my parents’ age, and they seem affectionate. A couple of men, too, watch me. This is because they don’t know who I am. Then my sister rushes towards me. She wears layers of black and long, dangly earrings. She squeezes me. Her scent falls on me lightly. She knows who I am and she still loves me. Is this all I have to hope for? I think of David, the mud on his boots, think of the way his trousers hang on his hips. I turn my attention back to the reassuring landscape of my sister’s open face. She is talking to me, fondly, impatiently. She is so used to me only half listening to her, half being anywhere.

  ‘You’ll have to join in a couple of times, you know,’ she is saying.

  I chance a reply, hoping it won’t be too much of a non sequitur. ‘You mean like at the panto? He’s behind you! Oh no he isn’t! Oh yes he is!’

  ‘You’ll recognise the first one from school. “All creatures that on earth do dwell”. You won’t be able to resist singing it, Nance. The second one’s harder. Let’s see if you manage.’ She passes me a ticket, kisses my cheek, cuts a dash. I watch her disappear to join the other singers. She is not afraid to have her back to me, or to anyone. She has not felt eyes boring through that back. Lucky Mark. What a thing, to have a woman like that. A mother. Soprano in a choir. A normal, loving female.

  I find my seat and look up into the vaulted proscenium of the concert hall. I am alone but, of course, much less so than normal because no one here knows who I am. I am by myself but no one shuns me. I could go away to a new place, I could start over, and no one would know anything about me. I could do smear tests and deliver babies and cover my hard core with layer upon layer of softness, and bury myself.

  The choir files in. They form a block. They look ahead. They take their physical proximity to each other for granted, the air that pools among them. The conductor walks on stage and bows. He is not young, but he is lean. There is virility in the depth of his bow and he is very happy to be in front of us all. I join in the applause, enjoying the convention. I like the innocence of the clapping. The choir straighten themselves. They would probably like to clap too. He is theirs and they must be proud.

  And then my thoughts switch to a different track, they are laid on runners of a particular kind when the music starts. Over a pulse of bass strings a violin starts a story which has anxiety in it, or suspense. My programme says Benjamin Britten’s Saint Nicolas. This is the tale of his adventures. But there is no point in my reading this, or knowing it. All the music can do is tell me my own story. It has already started to do this with the tension of the first few bars.

  The choir joins the orchestra. I am looking into a hundred open faces. I am looking into my sister’s own mouth. I feel a shock of embarrassment at this display of physicality, this extreme, loud show of the human body whose sounds usually come to me in private, overlaid with shame. Are they not shy, standing next to each other and letting themselves out like that? Do they not feel uneasy letting us all see them, as we tighten back against their talent, silent in the face of their song.

  I look up into the acoustic recesses of the hall. I let the music in. The tenor may sing of St Nicolas but he is telling me about everything that has happened to me and everything I have done. I think of my patient. The tenor’s tune sings my story round and about me. He sings to me of my mistake, of my patient’s near-death, my own collapse. Her stay in the Intensive Care Unit. My monumental error. Girls sing from the balcony. I refer to my programme and see they represent the wind in the gale. I look at Julia, who is directly in front of me. She bisects all the important angles in the room. I feel my huge love for her in chords which gather in layers. And I envy her this place where she can put all her feelings; that she can look pretty in black and mimic a storm with her voice, and rejoice in its resolution with her next phrase. And I have no idea how I have got it all so very wrong.

  When the choir pauses, it is as if they have heard my thoughts. When the conductor turns, smiling, encouraging, lifting his baton to the audience, I feel he is addressing me, directing himself at me. And when the whole congregation of the audience stands and the huge hall is filled with the sudden massive vibrating hum of every single person singing, of a sound that has multiplied massively in volume in just a few moments, I find I am one of the people that is making this happen. I do not rise slowly. I am already standing. I do not need to look at my programme for the words of the hymn I sang for years as a child. My strand of song rises up from my diaphragm like a great wave. Even though my throat is tight from my silent doctoring, I sing out nonetheless, and because I cannot hear my own strained voice in the multitude, I sing louder still and wish there were more verses than there are. And I know that there is nothing like this in medicine. Nothing at all like this in all the hospitals I have been trained in, even though we walk with death as our companion and though we are deep in disease and are present for the beginning of life and its end. When we all sit down, my eyes are full of tears.

  I do not find the chance to speak to my sister. I can’t pick the right moment. Before long, it is time to go back to London. No one begrudges me my last half-hour alone on the beach. It’s low tide when I sit on one of the groynes, the late afternoon sunshine at my shoulder, my boots immersed in the one sand pool that forms faithfully twice a day at the base of the last post. My back is warm from the sun, my thoughts still liquid warm from yesterday’s concert. But I have not carried into the new day any false sense that what I experienced then foretells my future tomorrow. I must go back to London and meet my fate, and I have no idea what decision awaits me there.

  The sky is windless. The tide is low and flat. There is no noise from the waves. What I do hear is the distant sound of the people on the beach, stretching out for miles on this fine afternoon. No one is near enough for their noise to reach me. I look at my boots and, moving them, observe the sound this makes. I imagine an audiogram, how I might plot the sound on a graph, frequency in hertz against volume in decibels. See how I order every detail of my experience into the file named Doctor. How on earth will I manage if I am erased, removed, struck off the medical register? I will lose my entire frame of reference. And what would I have to replace it? What is a doctor, if not a doctor? Take that title away and there may be very little left over.

  But, for now, I allow myself to bend my feet this way and that. Look at the water trickling through the creases of my rubber boots; concentrate on that pleasing low-frequency trickle, burble, mini-splash. Stay with this, concentrate on only this until, slantingly, I can push through consciousness into the place that lies just behind it. I have been afraid to let my mind go like this for months because of the images and all the thoughts waiting there to vex me, but I realise I can do it safely again now.

  If I keep my feet still, there is the thick varnish of the sea’s surface, one searing spot under the sun, the rest a mirror on which I can see the faraway clouds, the odd speeding gull measuring out angles on the protractor of the sky. I move my feet and the infinity of clouds and sky breaks, replaced by close grey folds of sand, small details of green weed and underside of miniature dead crab, segmented and blue. The near and the far, the yes and the no. Striking off or not. Forgiveness or not. Acquittal or not. Absolution or not. And even if they excuse me, this panel, can I excuse myself? What conclusion should I draw from the verdict I am given?

  I sit in the waiting room for the last time. The fact that I was at my sister’s house yesterday is irrelevant. As far as my judges are concerned, this is all I am: the fearful doctor, waiting to find out about her future career. But I am unlearning the skill of years. What has the last month brought me if not this, the realisation that a life is not like the way a doctor describes the life of their patient? Presenting complaint, history of presenting complaint, systems history, drugs and
social history, all in order before the examination findings are reported. All in order before conclusions are drawn from all of these things. I could laugh now to think of how I have prided myself on my social-history-taking, the bit so many doctors leave out altogether. How good I have felt because I always had some detail to tell about my patient’s domestic circumstances, if I did happen to get asked about them. I might have a hobby up my sleeve, a revelatory occupational hazard, a touching detail, the name of a pet, the shadow of a recent bereavement.

  Never mind that I have not done this as well as I thought I had. What a fool I have been to think I have been leading a life of my own just because I have held the fat bouquet of all these other lives in my arms, all the blooms just where they should be, at the end of the stems I have tidied and aligned and bound fast. And now I find this is no way to tell the truth at all, if one is trying to tell one’s own truth. So I will let a thing not follow the way it should. I will go from one place to another, without explanation. I will let myself, at long last, unravel a little.

  The chair I have chosen to sit on is green. I look at my watch. I am bang on time for my panel appointment. I feel the adrenalin in my blood, gathering full momentum again, heating my limbs, bringing a thin perspiration to cool my back, leaving no room for thought but only for an intense awareness.

  Nurses chatter in a nearby corridor. A radio, playing in the distance, leans towards the world outside. I notice the tight green stitching on my seat. Hear footsteps in the main hospital, beyond the walls of the waiting room, approach and fade. A fat black fly, on top of a lampshade, rubs dust from its feet. Sounds and minute irrelevant events orbit me, and stretch out from me in my stillness, seeming to occupy an age in space and time. I am in a pram in a park looking up into the rush of trees. I have fainted in a church. I am down in a dark cellar. My grandfather is dead, says my mother. I am standing in front of a classroom of children, reciting a speech. I am waiting to turn over an exam paper and muttering a poem to calm myself: ‘O why do you walk through the fields in gloves, missing so much and so much? O fat white woman whom nobody loves …’

  The door opens. It is Dr Garber. ‘Come in, Nancy,’ he says – and I am reeled back into the world with one spool, drawn back into my body again, where I find my limbs trembling, yet my voice despite everything knows how to say ‘Hello’, and my face is able to regain tone in order to flex into a little smile before returning to the neutral. I walk into the room and take my seat.

  I look at them in turn. And everything is just itself again while also being quite different, seeming to hold within itself the possibility of anything at all, the potential for absolute change lying just beneath the surface of what I see, of what I am managing to inhabit as normally as I can. The features of the room flatten to the occasion. I shut the other versions out, forcing the details to take a back seat, allowing myself to focus on what I am now ready to hear. It is Miss Mansfield who speaks.

  ‘Good morning, everyone. We are here for the last time today to make a decision on a case of clinical negligence brought to our attention just over a month ago. The three of us were appointed to this task by the Chief Executive of this hospital trust, under the aegis and approval of the General Medical Council. First of all, I would like to thank everyone here for the responsible way in which these sessions have been conducted. It is certainly a source of satisfaction to me that we have not needed to refer this case back to the GMC, that we have managed to deal with it here, locally, up until this point.’

  Because she is sitting next to her co-panellists, Miss Mansfield isn’t able to get much recognition from either of her colleagues for this opening speech, but I smile at her. She looks so much more comfortable like this, speaking formally, than she has, unscripted, during previous sessions. She’s back on home ground, I suppose, inhabiting the muscular clauses all those bone-breaking orthopods she works with would enjoy. I have missed a bit now, I realise.

  ‘… Dr Garber. After he has finished taking us through the findings from the psychiatric assessment, I will deliver our verdict on what happened in Theatre 3 exactly five weeks ago today. There will be plenty of time at the end for discussion or to explain anything that is not completely clear. Nancy, do you have any questions at this stage?’

  ‘No, thank you,’ I reply. I am keen now to hear what everyone has thought of me. It has been impossible, this past month, to establish what I think of myself. I wonder if I have said the last thing I am ever going to say in this room. There won’t be any point in questioning their judgment, will there, once it has been made? And I’ve had my chance to speak already. Suddenly I feel a great heaviness in my heart at all the things left unsaid during these hours.

  Miss Mansfield finishes her speech, and now it is Dr Garber’s turn. He glances from side to side at his colleagues, even though they are both looking down. He looks up from his papers to meet my gaze.

  ‘Dr Gilchrist has written a pretty comprehensive report,’ he says, indicating with a slim thumb that there are many pages before him. His face is pink. This is a big day for all of us, I suppose.

  ‘… beginning with his Mental State Examination, in which he describes Nancy’s mood as having been congruent throughout, with normal variation in affect during the different parts of the interview, although some reduction in facial expression. No evidence whatsoever of pychotic features … da, da, da. Nothing relevant in the past history, normal childhood and school history, no past psychiatric history. No drug or alcohol issues. Oh yes. Moving on, this is an interesting bit here. Dr Gilchrist says that there are strong correlations between Nancy’s case and others he has seen before. Actually, this is his special area, post-traumatic stress disorder.’

  He holds his hand up, asking for us to bear with him. He reads for a few moments to himself, muttering and humming the words in front of him as he takes them in, ruminates on them, gets them ready to bring out again. After a few moments he looks up, first to Miss Mansfield, then to me.

  ‘So, there is, apparently, a subset of post-traumatic stress disorder called perpetration-induced traumatic stress. The original research came from studying veterans from the Vietnam War. And these guys, the soldiers, well many of them came back in a mess after that time. We all know that, right? But what this research shows is that the stress reaction, the psychological disintegration, was observed to be extreme in those who had actually killed people in Vietnam. And now, Dr Gilchrist says, that original research has been applied to all sorts of workers whose occupation involves them in killing: vets euthanising animals, executioners. Even abortion providers …’

  ‘Tim, where is this all leading?’ asks Miss Mansfield.

  ‘Look, this is not the main conclusion that Dr Gilchrist is drawing, but it’s really important, I think. Actually, we have a PTSD group at the surgery that we’re really making some progress with, so … my point, Dr Gilchrist’s point, is that many of the symptoms Nancy has experienced, what he calls the eidetic dreams – the dreams which seem to replay the event – the sense of social isolation, the freezing-up in theatre are cardinal features of this syndrome. Given that this session is taking us towards a verdict, I think it’s important that we spell out for Nancy that what has happened to her may, in the view of this psychiatrist, have arisen directly out of the kind of work she has chosen to do.’

  Well, that’s a pretty package, I think to myself. A nice neutral report. Nothing wrong with me, honest, Guv, it’s just the job I do. I wonder what will come next.

  ‘Dr Gilchrist’s conclusion is – well, look, I’ll read you a bit. “I could find no evidence of a continuing or chronic condition. If pressed, I would categorise this according to ICD-10 criteria as F43.0, an acute stress reaction. However, I have also noted similarities between this case and a subsection of post-traumatic stress disorder known as perpetration-induced traumatic stress, whose features include obsessional thinking, depression and fatigue, identity conflicts and withdrawal from colleagues. While I do not see any immediate danger of
a repeat crisis as long as this young doctor reconsiders her line of work, I do recommend that—”’

  ‘Tim, let’s hold the recommendations for now. I think it would be best to give these, Dr Gilchrist’s and ours, such as they are, a bit later, after we have given Nancy our decision. Do you agree?’

  Dr Garber shuffles his papers together at this request. He looks pleased and important, happy for Miss Mansfield to take over again. After focusing on the GP, I notice again how upright she is, how perfectly done.

  ‘Nancy, it’s been an interesting few weeks. It’s clear from the long discussion Tim and Vivien and I have had, that we had yesterday, about you and what’s happened, that there isn’t one of us on this side of the table that hasn’t benefited from the experience. Speaking personally, some of the things you have said over the weeks about the fragmentation of patient care have struck a real chord. When I was a junior doctor, we worked in firms. We had an SHO and a registrar and a consultant whom we stayed with for months. We saw our patients come into hospital, and we were the ones to wave them on their way. Whatever else we’ve gained, we’ve lost this. You’ve reminded me of it, Nancy, and I think we’ve all had sympathy with what you’ve argued so strongly in this room, that the doctor’s relationship with their patient is sacred and should be protected.

  ‘I want you to know that Dr Garber and I sit on the Clinical Governance Committee of this hospital trust and we will make it our duty not to let this matter drop. We are going to take what you have reminded us of, Nancy, to that committee, and see what we can do.

  ‘The next thing to say is that Dr Gilchrist’s report is not the only one we have had the benefit of, Nancy. We have gathered references from all the consultants you have worked with, and from the Dean of the medical school here, as to your conduct as an undergraduate. There has been nothing whatever in any of these references to suggest anything other than a hard-working, honest doctor, with great potential.’ She pauses and looks at me and adds, ‘The kind of doctor I would welcome as a trainee, I might add.’