Growing Into Medicine

by Ruth Skrine

  At the time I was not aware that the most intense period of my life as a mother had come to an end. As this memoir reaches the adolescence of my daughter I have made a deliberate decision to neglect the major part she has played in my life. She has her own view of her father and of our marriage, and has generously made no complaint about this account of our family from my point of view. Her own journey into medicine, marriage and motherhood belongs to her and is not mine to tell. My love for Helen is the living centre of my being. But the themes that are developing in this story do not need to include the details of her life or those of her family, although I will not be able to stop them creeping in from time to time.

  I find it hard to identify my feelings as the beginning of her first term away from home drew near. I did not believe I had been a very successful mother. I was too anxious and, though I don’t like to admit it, easily bored by the unremitting demands of a child. At the same time a fear that my family was falling apart led me to buy a dog. We visited some kennels where a litter of Welsh Border collies waited for new homes. At the front of the cage two male pups scrabbled for our attention while a timid bitch cowered against the back wall. Instinctively I chose her, identifying with her shyness. She was a bad choice, for although charming she grew up to be very nervous, made worse by the fact that she lost an eye due to disease soon after we collected her.

  Ralph chose her name. It was not as good as those he chose for the baby guinea pigs and our cats, because Biz is known as Bess in the US, which led to some confusion. But he seldom offered an opinion about domestic details so I never demurred when he did make a rare suggestion. In the same way I was landed with a hideous carpet because he had, in an uncharacteristic moment, agreed to view my choice of floor covering before I bought it. On the way into the shop he saw one with a monstrous green and yellow pattern – and liked it. I acquiesced, too pleased that he had taken an interest to argue.

  For the first time we did not live in provided accommodation but bought our own house in Wakefield. It was on a corner with a low wall separating our garden from the pavement. To keep Bess confined we had a fence erected on top. Cadets from the police training college round the corner used to run their truncheons along the struts, exciting Bess to a state of frenzy. She grew up with a fear of all men walking alone and would chase them, barking and snapping, a constant worry when I let her off the lead.

  As a child, I squirmed when my mother said, as she did frequently, ‘We are animal people.’ I could not bear that ‘we’ for I knew she meant all five of us. She used the term frequently about beliefs and behaviours that I did not necessarily share, though I never complained. In contrast I glowed when one of my grandchildren referred to his family as ‘we’, giving the impression that he had a safe base from which he would be able to separate with confidence. In his mouth the word was reassuring, while my mother’s insistence on unity was stifling. Perhaps this was another reason why I felt I had to give Helen as much freedom as possible, however much I might want to keep the family together.

  Another quibble with my mother’s assertion that we were animal people is that I have never been as moved by or involved with animals as my sister. Until Biz had her own children she preferred animals to humans. She trained as a zoologist and has run a small herd of cows on her farm in Virginia for most of her married life. She welcomes unusual pets, especially snakes and other reptiles and amphibians. There was often a black snake in her bedroom. Aware of my phobia about things that slither, not helped by the worm Arthur put down my back when I was young, she never insisted that I handle it. Her dining room also contained a small iguana for many years, kept in a cage on a side table. Earlier, when I developed acute back pain during one of her visits, I had shared the green bathroom with her opossum.

  I cannot compete with her knowledge and gentleness but fully agree with the belief, which has been passed down the family over at least five generations, that pets add much to a household. Children have a chance to see that even a relatively self-sufficient cat needs regular attention. Animals also offer channels for emotions that we English cannot always express. When my grandsons arrive for a visit, the task of finding and petting the cat eases that awkward moment after the first greetings have been exchanged. Throwing a ball for a dog in the garden, feeding carrots to the rabbit, visiting a neighbour’s horse are shared occupations that can bind disparate members of a family who may share few other interests. I am not in favour of kicking one’s cat but it is less harmful to shout at him than at one’s spouse. In her increasing dementia my much-beloved cousin Jenny has a Labrador who provides a degree of unquestioning devotion that few human beings could offer so consistently to someone who is seriously confused.

  Whether my delayed commitment to animals was an effort to maintain the semblance of a family, or to provide a more interesting home for Helen during the holidays, it is clear that my life had entered a new phase. I was continuing the journey to free myself from the need to react against, or conform to, my parents’ beliefs. The process had started when I defied my mother by marrying a diabetic in church wearing a white dress. The magnitude of that defiance made it both easier and more difficult to take my own decisions, whether they were about pets or work.

  With Helen away at school I had more time and energy for my profession. To the bemusement of my parents I did not consider looking for work in general practice, for I had developed an increasing fascination with the challenge of helping people find a contraceptive method they could use effectively. I was discovering that although doctors and nurses must have adequate scientific knowledge, the skill of helping each individual person is closer to an art or craft.

  Unfortunately we still do not have a perfect method of contraception, one that is free of side effects and acceptable to everyone. Choices have to be made. Before the 1960s the only methods widely available in the UK were periodic abstinence (the rhythm method); withdrawal of the penis before ejaculation, known as ‘being careful’, ‘pulling out’, ‘stopping at Darlington’, and other synonyms; spermicides; and the barrier methods of condoms and vaginal devices. By the time I did my training we had oral contraceptives and intrauterine devices (IUDs). Hormone containing IUDs and injectable progestogens did not become available till later.

  One of the first things I learned was not to make presumptions about a patient’s beliefs. At that time, in the early 1970s, Catholics were supposed to use no ‘artificial’ method of birth control but to depend on the rhythm method, also called Natural Family Planning. During my work I met some Catholics who would not consider anything other than this method, which depends on abstinence from sex except during the infertile times of the menstrual cycle. The safest time is after ovulation, calculated with the use of a diary, temperature charts and/or monitoring subtle changes in the body.

  For those who wanted to use the method it was important to find someone with the patience and time to teach the details and to provide enthusiastic support for its continuing use. Because of the high failure rate many doctors – I was one of them – found this task difficult. Some family planning nurses became experts and the church itself provided counsellors in many places. As doctors we were faced with the task of referring the patient in a non-judgemental way while at the same time weighing and explaining the medical risks for that particular patient if the method failed.

  If the doctor herself had a strong religious faith, not necessarily Catholic, the task could be easier. My friend and family planning pioneer Elizabeth Gregson worked in the domiciliary service in Liverpool. She was asked to visit a harassed mother of eleven children. After spending some time in the overcrowded house, she realised that the priest was behind the woman’s intransigence. In desperation Elizabeth, a committed Anglican, approached her bishop who spoke to the Catholic bishop who had a word with the priest. The upshot was that the woman could discuss contraception more freely and eventually decided to opt for sterilisation.

  Despite their strong faith, Catholic women had many differ
ent views. I was envious of those whose religious belief provided the support in their lives for which I have always been searching. However, the experience of resisting my mother’s evangelical atheism might have increased my sensitivity to individual variations. Some women were happy to take the pill but could not use any sort of barrier method. Others felt it was wicked to take drugs but they would use condoms and occasionally a vaginal diaphragm. The IUD was particularly acceptable although, because the early devices probably worked by preventing the fertilised egg fixing onto the lining of the womb, the belief that it was a form of abortion could make it unacceptable. Devices containing copper or hormones are more usually used nowadays and probably act by changing the fluids in the reproductive system, preventing fertilisation. Another advantage of all IUDs was that a doctor fitted the device; the patient had to take no active steps of her own. Other women, no matter what their religion, liked it because of the slight but real failure rate. One patient, who felt she should not have any more children for financial reasons, told me she still felt unfulfilled. ‘If I did get pregnant with the coil it would not be my fault,’ she said, her face radiant with the thought that contraceptive failure, not her own rash behaviour, could give her the additional baby she longed for.

  I had been trained to insert coils in London but at that time they were fitted in designated clinics. I never ran one of these and although I became reasonably proficient I knew my limitations. With my dislike of emergencies I always feared that the patient would go into cervical shock, a sudden drop in blood pressure leading to pallor and faintness caused by the insertion. In fact it happened rarely. If it did, the patient usually recovered quickly when laid flat, reassured and given painkillers. Only once or twice did I have to take the device out. I tried to avoid such collapse by referring any patient who might have a difficult insertion, such as women who had not had a baby, to someone more experienced.

  Even today Catholic teaching, that only the rhythm method is allowed, is strong in many parts of the world. The recent relaxation of advice from the Vatican, allowing condoms to be used to protect against infection, is more than welcome and long overdue. On holiday in Tanzania, in 1994, I attended a church service and saw the strength of the Catholic faith. The building was packed with the congregation in their most colourful Sunday best, doing justice to the blue electric candles on the altar and the length of the sermon. In the secondary school a nun provided the only sex education. She taught nothing but complete abstinence until marriage. The powerful local priest vetoed all other information. In my chatty way I asked one of our guides if he were married. He told me firmly that the question was impolite, not one to be asked in his country. When I got to know him better he confessed that he had three children, all with different women, but had never been married.

  One teacher at the school had already died of AIDS. Someone whispered that the headmaster would provide condoms if he suspected a senior boy was at risk. On leaving, I left a package containing a simple book on contraceptive methods and some money with instructions that it be spent on nothing but condoms. I never heard if my wishes were carried out.

  In a recent issue of the Journal of Family Planning and Reproductive Health Care there was a discussion about whether nurses should be trained in the use of intravenous atropine for cervical shock. I was impressed to read that some nurses had been fitting IUDs for twenty years. I remember trying to teach a nurse to do a bimanual examination of the uterus to discover its size and direction, an essential procedure before fitting an IUD. I was struck by her lack of familiarity with the feel of the internal organs. As doctors we had been feeling for enlarged livers, kidneys, spleens since our first day on the wards. The resistance of the abdominal wall, the degree of pressure needed, somehow the distance of the organ from the fingers, were all new sensations for the nurse. But I am sure that with adequate training, supervision and experience a nurse will be as safe as a doctor, safer than someone who is fitting them less frequently. The only time, to my knowledge, that the uterus was perforated in my presence was by an overconfident obstetric registrar, someone who should have known how much force to use. The patient had recently had a baby and the uterus can be very soft at that time. She felt no pain, the device being found in the abdominal cavity on X-ray later.

  Since the first two years of my marriage, while I was completing my training, relative subfertility and my wish for another baby had removed the need for us to use contraception. My belief that I was therefore not influenced by personal prejudices about the methods was misplaced. Because of my dislike of fitting coils I probably did not promote them as strongly as I should have done. In the same way, because I had not minded using a diaphragm, and enjoyed the simple task of fitting them and teaching their use (a job now carried out by nurses), I was happy when a patient chose to try one. I hope I resisted the temptation to encourage that method over others. One of my colleagues had become pregnant using one and admitted she hated the premeditation and messiness. It must have been hard for her to sing the praises of a method that had failed for her personally. All we could do was to be aware of and try to make allowances for our personal biases.

  Helping the individual to assess the risks and benefits of different methods was also difficult. I was beginning to appreciate the difference between the ‘theoretical effectiveness’ of a method and its ‘use-effectiveness’. Bob Snowden, in his foreword to the book Contraceptive Care, which I edited with Heather Montford, defines the latter as the ‘rate of unwanted pregnancy in terms of the experience of the couples using the product during the emotional and physical somersaults of their love-life’. If someone said they did not want to use a method it was important to find out the details of why she or her partner felt so strongly. One could quote the known failure rates, the possible side effects and the statistical risks compared with those of pregnancy. They made little sense to a patient who said, ‘My mother was using a cap when she got pregnant with me.’ The girl whose best friend was admitted to hospital with a deep vein thrombosis soon after starting on the pill was not likely to be amenable to reassurance about its safety. On the other hand, if the fear was about gaining weight, then the strength of that fear had to be assessed by her reaction to the information that not everyone did so, and that there was a range of possible pills she could try provided there was no family history that might put her at greater risk.

  The feelings of the usually absent partner are also important. There are times, for instance following delivery or while getting settled on a pill, when the use of a condom appears to be the best method. If the woman says ‘he doesn’t like them’ one needs to know if he finds it more enjoyable without, or whether he loses his erection every time he tries to put one on. It could be reasonable to ask him to put up with the first for a limited time but possibly devastating for their relationship to press a method that leads to repeated failure of all attempts at love-making.

  During these consultations patients often revealed sexual difficulties. The old adage holds true: contraception is not about avoiding babies, you can do that by not having sex. Thus every request for family planning is an unspoken plea to be allowed a sexual life. From there it is not such a big step to confess that the act is not much fun or doesn’t work properly. During my medical training such subjects had never been mentioned. I felt so useless in the face of such human distress that I joined a group in Sheffield.

  The leader of the group was Dr Lawton Tonge, a gentle and intelligent psychiatrist, who knew of Tom Main’s work with family planning doctors in London. But he accepted doctors, nurses and social workers into his group, while Tom was never in favour of training different professionals together; he believed that the expectations and pressures on each group were very different. In addition he felt that their rivalry interfered with the efficient working of the group. I have always agreed with this view though I realise that the idea of teamwork is now politically correct. Arguments about this subject still rage in training organisations like the Institute of
Psychosexual Medicine.

  At the first meeting I experienced the typical antagonism of an established group towards a newcomer. Someone grudgingly pointed me to a chair but did not offer me a cigarette when she passed the packet round to the others. I am sure they did not mean to be unkind but the action has remained a powerful demonstration of group solidarity. As I relive the moment I am also surprised that a group of health service workers were openly smoking and encouraging others to do so. The accepted behaviour feels as dated as the Edwardian nicety of calling cards, an equivalent social gesture, yet it was barely forty years ago.

  The most lasting outcome of that group was my friendship with Doreen Anderson, who was also a family planning doctor. She introduced me to the lovely woods round Newmillerdam where we walked our dogs together. We had a lot to chat about as we strode out beneath the new green of spring or crunched over fallen leaves in autumn. Doreen is a Scot. When I last visited her in Cumbria, where she has retired, I felt again the attraction of her lifestyle: her love of walking, home-made muesli and abundant vegetables grown by her husband. I envied her stories of mountains conquered and nights spent in her caravan. Ralph had never responded to my interest in camping and insisted that he had walked enough in the army to last him a lifetime. However, my romantic notions of simple holidays close to the earth did not stop me enjoying the expensive hotels he chose and paid for.

  He earned a reasonable salary but had, in addition, a small income from a family trust. We were never short of money, yet from time to time I was disgruntled. He paid me a housekeeping allowance that was meant to cover the help I employed in the house, all the bills and food. It never occurred to him that this was anything but generous and apart from an occasional splurge on a new car he spent little on himself. He encouraged me to spend my own earnings in any way I liked. In my view I used much of that personal income to subsidise our expenses; but being too lazy to keep accounts I had no grounds to argue my case. We did not talk about it and I never voiced my vague feeling of discontent. I imagine a modern woman would chide me for being spineless but, if I had cared enough, surely I would have kept the records to prove my point?