by Ruth Skrine
When summer arrived, Ralph and I spent our holiday in our canoe. Our wedding presents to each other had been the front and back halves of a double-seated kayak. The wooden struts were covered by canvas and collapsed into two bags. We had set off on our honeymoon in the Austin Seven with them strapped to the roof rack, choosing to go to the Vosges mountains, not a very suitable location for easy paddling though we did camp for two nights on an island in the Moselle river.
The norm in the 1950s was one annual two-week holiday, with shorter breaks in lieu of Christmas and Easter. We managed to visit our parents for one or two weekends a year. The drive, only about 175 miles, took at least six hours for there were no motorways. We returned laden with bottles of soup and Christmas puddings from Ralph’s mother and good advice and plants from my own.
Our next canoe trip was down the river Cherwell. The water was very low and after two days carrying our craft over reeds and across fields of new-cut hay we abandoned the effort and changed onto the Oxford canal. We became adept at portaging round locks but by that time we realised we were not comfortable in the same craft. Ralph sat at the front and I could not adapt to his quicker stroke. We invested in two singles for our excursion the following year when we embarked on a stretch of the Wye. Now we had the problem of getting in and out. In one canoe we could steady it for each other but my clumsiness made it difficult for me to step in without such help. In addition, the Wye flowed fast and we were not ready to face rapids. We were supposed to be good on rivers and were a bit embarrassed when we gave in and transferred to the more leisurely Stratford Avon.
But the rest of that trip passed in great contentment. Motorised craft were forbidden; indeed they would not have been able to travel far, as there were no locks by the weirs. We drifted in isolated silence. On the last day the air became heavy with an impending thunderstorm. As we slipped silently past a bed of reeds we saw a bittern standing, unaware of our passing. Later I hardly noticed the rain thudding on our tent and the moisture seeping in as I relived that shared moment of wonder.
I worked as the casualty officer for the first few months of my second year. That job included some minor surgery. I circumcised babies – the reek of Friars Balsam soaking the strip of lint that we tied round the mutilated organ is with me still. I also had to change supra-pubic tubes, permanent bladder drains through the abdominal wall in old men whose prostatic enlargement could not be relieved. I hated the task. The smell was overpowering and the procedure painful. One man started to whimper as he came through the door, and his shriek, as I yanked the tube out, echoed down the corridors and in my mind down the years.
Another common problem was breast abscesses. These occurred in women who were breast-feeding and are not seen so often now. Perhaps we did not recognise them in time or give adequate doses of antibiotics. It was important to break down all the fibrous compartments with a gloved finger and I used to feel brutal as I poked deep into the tissue.
During that time we had the chance to see the work of general practitioners from a particular angle. My parents’ old adage that doctors were either ‘poo-pooers’ or ‘wind-upers’ was borne out. One man brought his patients in almost every day. His lack of confidence was in striking contrast to our ill-founded certainties. We laughed at him and had little understanding or sympathy for a man who had lost his nerve. Others referred serious cases with dismissive notes: ‘Please see and treat’. One conscientious doctor often joined us in the common room for coffee and chat. He was lonely, but also still genuinely interested in medicine and wanted to be close to the centre of things. I often found his suggestions helpful.
My appointment as a junior medical officer in geriatrics came as a relief, although it was not without its horrors. Long wards filled with all kinds of physical and mental suffering stretched into the distance. The smell of disinfectant was overpowering but at least the place was clean. One woman had half her face eaten away by a malignancy. Some of the patients called endlessly for help, others dragged themselves to the bathrooms from which, on the male wards, men would emerge with their trousers round their ankles.
The idea that old people needed a special medical approach was only just developing. The hospital in the neighbouring town of Castleford had been the old workhouse, and was now classified as ‘part-three’ accommodation. The patients had been confined to bed for years without investigation, diagnosis or rehabilitation. I was lucky to have an enthusiastic consultant who was determined to sort out the medical problems of the inhabitants in order to diagnose and treat the treatable. He was one of the first specialist geriatricians who realised that rehabilitation was crucial in the fight against what were called the ‘Giants of Geriatrics’: Immobility, Instability, Incontinence, and Intellectual Impairment. He fought hard against entrenched positions, building a multidisciplinary team to tackle the problems.
I also worked on a ward in Wakefield, another twelve miles beyond Pontefract. By that time I had exchanged my small car for a Ford consul convertible. For me a car is a means of getting from one place to another, not an object of interest or emotion. But I loved that first vehicle that I had bought with my own money. It was pale green with a fawn hood that folded right back. I drove under the sky with the wind in my hair and the wireless blasting, so that the sights sounds and smells of hospital were blown into the ether.
I was now getting back to Pollington every evening having driven up to fifty miles during the day. It never occurred to me that our marriage was not secure although we were clearly not a close couple at the time. Our love life was pleasant although not totally satisfying until several years later when Ralph bought himself a book on sexual technique. At no time, even years later when I became more comfortable with the subject, could I have shown him, far less told him, what my body liked. My personal shyness never abated, but I hope that perhaps it helped me to empathise with some patients.
By the end of that second year in hospital, my wish to be a nurse forgotten in my passion to be a better doctor, I had been shut up for most of the days and many nights with a variety of unattached, attractive and helpful men. We worked in the highly charged atmosphere of life and death. At Christmas and for some birthdays we gave small parties in the common room where drink flowed. On two occasions I found myself tempted into a cuddle and some kissing, but it never went very far. The idea that it was wrong to seduce a married woman was still strong and the men helped me to remain faithful to Ralph in a way that might be more difficult today.
I believed I had kept these lapses well hidden. When we heard that we were to be moved to Portsmouth I was not surprised for I knew that governor grade staff were moved fairly often. It was only many years later that Ralph told me he had requested a transfer because he thought our marriage would not survive if we continued to live such disparate lives.
8
General Practice
Our quarters in Portsmouth consisted of a two-bedroom ground floor flat, outside the walls of the prison. The sitting room was long and narrow with the fire on the short wall. In an effort to get warm I sat so close that my legs developed brown marks, which took a year to fade. The kitchen looked out onto the wall of the house next door with room between for nothing but dustbins. The tiny front garden faced a busy main road. My mother planted two cherry trees; despite the pollution they flourished and were a good size when I drove past ten years later. By the start of the twenty-first century the area had been flattened and redeveloped.
I was lucky to find a post as a trainee general practitioner. The scheme had only recently been devised and was not yet compulsory. It consisted of just one year’s training. Such scanty preparation must be hard for today’s trainees to imagine. Now they have to work a mandatory two years in hospital, followed by three years’ training for what is recognised as the speciality of general practice.
I had sampled the world of medicine outside hospital even before we moved to Portsmouth. After my first year in hospital I was free to be let loose on the public. I took a job f
or two weeks as a locum in Ackworth, a village three miles from Pontefract. We knew the doctors to be conscientious, although in our view from hospital somewhat over-anxious. The senior partner went on holiday, leaving his junior to keep an eye on me. Faced with the undifferentiated illnesses of general practice, most of them minor but with an occasional emergency not to be missed, I was completely lost. I hardly knew how to write a prescription, having used nothing but the bed-end charts on the wards, where my drugs were checked by a competent ward sister and again by the hospital pharmacist.
This was the moment when I started to ape my mother by wearing a coat and skirt, perhaps in the hope of annexing some of her confidence. The small BNF lived in my pocket, as it had done in my white coat in hospital. It was my Bible. I did not have the confidence to refer to it in public, as I learned to do later, but I consulted it while the patient dressed behind the curtain, on hasty trips outside the consulting room or in the car between visits. I soon realised that patients were not happy if I challenged their own doctor’s advice. Wherever possible I would repeat what the regular doctor had already prescribed.
One woman stays in my memory. She was a hotel proprietor, on her feet all day. She asked for a visit because her foot was painful. Arriving at the large building I found she had slight swelling and tenderness over one of the long bones of her foot. I thought it was probably a strain but it could have been a ‘march fracture’, a spontaneous break due to physical stress on the foot. Coming from hospital, where we tried not to take unnecessary X-rays, and knowing the treatment would be the same, I strapped the foot and told her to rest – I don’t remember discussing the difficulties of doing so when she had a hotel to run. When her own doctor came back he ordered an X-ray and it did indeed show a hairline crack. The patient was furious and considered me negligent despite the fact that the treatment was not changed.
The same problem could arise with a simple cracked rib. In hospital, provided we were sure the lung was undamaged, we were encouraged not to ask for an X-ray. In those days we applied tight strapping to the chest. (This is no longer advised because of the fear of infection in the less mobile lung.) Doing the simple task with care was one of the few occasions when one could provide immediate relief from discomfort. Another was syringing ears. A modicum of skill was needed in those days when we used a metal syringe: the appropriate pressure had to be applied in the right direction. Since then the ear irrigator has been developed. It allows electronic adjustment of pressure and the task has been delegated to nurses.
I now realise that patients need to know what has happened to their bodies, especially if a bone is broken, even if the knowledge does not affect treatment. A sprain is just a sprain, but a broken bone elicits more sympathy from family and friends and justifies a longer convalescence, even though a bad sprain can be more troublesome than a clean break.
My trainer in Portsmouth, Dr Burnham-Slipper, was a well-established and conscientious general practitioner. At that time there was little supervision of trainers. Some were exploitative, benefiting from the fee they were paid but using the trainee as an extra pair of hands to help shift the considerable burden of work. I was lucky to have found a man who gave freely of his time and took his training role seriously. For the first time since I had obtained my degree, I felt adequately supported. For at least three weeks I sat in on his surgeries and went with him on home visits. When I started to consult alone he was always in the next room, available to give advice if I was in any doubt about a diagnosis or management. When I started home visiting by myself, we met over lunch and at the end of the day to discuss cases.
The routine in Portsmouth was very similar to the one I had observed as a child. In both practices long surgeries were held twice a day, on a first-come first-served basis, the queue of patients overflowing the small waiting rooms. In Chippenham they had perched on the walls at the top of the surgery path which ran along the side of Lowden Hill. In Portsmouth twenty years later there was less room for the patients to wait and they would spill out through the small front garden onto the road.
All GPs in those days made many house calls, in response to requests for new visits, to follow up cases and to a list of regular elderly patients. However, there was no local hospital run by the GPs in Portsmouth as there was in Chippenham, where my father did a ward round each day, with an opportunity to drink coffee and talk with other doctors in Matron’s sitting room.
Under the NHS, introduced in 1948, hospital medicine was advancing and becoming more organised. Because the system I was now working in was so similar to the one I had known as a child, I was not aware that general practice was falling behind, becoming the poor relation. Doctors organised their own practices, perhaps with the help of a wife or secretary. Partnerships were small, usually two or three doctors often working in different premises. Nursing and midwifery services were separate. Individual doctors and nurses might try to work closely, but the employment of ancillary staff within the practice was still a long way off. Above all, this was a patient-driven service, the doctor responding to immediate demands. Preventive medicine was limited to the vaccination and inoculation of infants, usually carried out at clinics run by the medical officer of health and his staff.
It is now twenty years since I did any work in general practice. The changes have been profound. My son-in-law Simon, who practises in Swindon, worries about the efficiency of his practice manager, reaching his targets for screening and health promotion and his work in a deanery where he oversees the trainees and trainers. With cars so widespread most patients can drive or get a lift to the surgery so he makes far fewer home visits. He often sends patients with an acute illness directly to the hospital where the range of useful interventions has expanded beyond anything my parents could have imagined.
One of the most dramatic changes is in the treatment of patients who suffer a stroke. My father had several partially paralysed patients on his routine visiting list. One lady limped about her house with a useless hand and impaired speech. I was embarrassed by her handicap but intrigued by her white cockatoo with a yellow crest that shrieked ‘go away’ and ‘lovely boy’ when we visited. She would let it fly loose and cuddle it, allowing me to stroke its back with one finger. When she first suffered her stroke she had been nursed at the hospital. But her calamity had not been considered an acute emergency for there had been no immediate treatment – patients either died or lived with varying degrees of disability. In recent years, specialist stroke services have been set up in many places. If the patient can be seen, scanned and a treatment regime started within two hours the outcome can be significantly improved.
The definition of a general practitioner that I was trained to fill was ‘A doctor to the individual, his family and a practice population’. I have always thought that the roles were not totally compatible. The conflict of interests has become more severe since the rise in patient expectations, the emphasis on preventive medicine and on financial considerations, made so much more acute by the challenge of scientific advances. But the individual patient is still preoccupied by the immediate symptom or anxiety. Health education and routine screening can feel irrelevant at that moment, and the focus of the doctor’s concern may be deflected. I wonder how much the pressures on the doctor to fill many different roles underlie the discontent that I hear from so many elderly friends, who feel their doctor has no time to listen or empathise. When my father visited his chronically ill patients he had little BUT time to offer. Despite the major organisational changes, appointment systems, computerised records and teamwork, the heart of primary care remains what it has always been, a meeting between a troubled patient and a doctor wanting to help.
After my year as a trainee I stayed on in the practice as an assistant. Ralph was now working with adult prisoners for the first time. Some of these were serving life sentences for murder, and his contact with them stimulated an interest that began to take the place of his concern for young people and was to last him the rest of his working lif
e. He worked more civilised hours so we could spend most of our evenings together. There was no room for his archery in our cramped quarters but he joined a judo club. Although I was becoming more tolerant of his strange hobbies, when he filled our bedroom with weight-lifting equipment I was irritated. We still went to western films but I was getting used to the guns. Our relationship was strengthened by a couple of very enjoyable holidays driving round France and Italy. However, my personal concern was that I did not seem to be getting pregnant.
Both my parents had stressed the disaster of getting pregnant before I was qualified, but as soon as I had those precious initials after my name I had stopped using my contraceptive diaphragm. After three years I saw a consultant in Bath who gave me temperature charts to try and discover if I was ovulating, a passion-killing device of the worst sort. After a few months it showed no rise in the middle of the cycle. I was not producing egg cells. It was senseless to feel we had to perform to order. I took the various ineffectual hormones available at that time and tried to concentrate on my work.
Two patients stand out in my memory. The first was a woman in her thirties, desperately ill in the last stages of septicaemia and kidney failure. By the time she plucked up the courage to send for me she had passed no urine for two days. I called the ambulance and sat on her bed while she confessed that she had been to an abortionist, a local woman who ‘helped’ women in trouble. She died three days later. The unnecessary death of that patient, caused entirely by the laws and social mores of the times, has haunted me to this day. The year was 1956 and I will never forget the desperate plight of so many women before the abortion act was passed eleven years later. If one had money, or a friend with the right connections, a gynaecologist might be persuaded to perform a D&C on some pretext such as irregular periods. If one had no such advantages the back street abortionist with her knitting needle or other unsterilised implement was the only answer. Sex education was totally inadequate and the pill was still a dream in the mind of a few research scientists.