Growing Into Medicine (17 page)

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 different 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?

In retrospect I wonder if I needed something on which to pin a vague dissatisfaction. We were very different people. I once said to Helen that the bumps on his head fitted the dents on mine. She flashed back, ‘The bumps on his head
made
the dents on yours.’ My role as the one who did the bending made me look like a martyr, but I was well aware that my dents had always been there. Ever since the days when I looked under the bonnet of cars with my father, or sat with Arthur while he made things, I have needed to tend the men in my life. Because Ralph was the late son of a family who had waited a long time for their male heir, and had been brought up by a doting
mother with the help of a clutch of servants, he took the attentions of a devoted wife for granted.

As a tutor at the college, Ralph’s daily life must have been very different from that when he was governing a prison, but the subject was not discussed between us. For me, the most important aspect of the way we interacted was that he never, ever, tried to influence the type or amount of work that I undertook, leaving me free to choose the balance of my life to suit my own needs and interests. Throughout this time our holidays became increasingly important. We bought a cabin cruiser and travelled the inland waterways. From the beginning I loved the altered view, as if one had crept inside someone else’s skin and was seeing the world through their eyes. Cities were more appealing when seen from the inside, the underside. Looking up at crumbling walls and rusty winches, relics of a time when the canals were commercially viable, the weight of history provided a perspective that ridiculed my anxieties about the small world of work and family. Out in the countryside, the eye-level hedges flashed dog roses, unexpected splodges of simple blooms draped over brambles that would bear inaccessible blackberries in the autumn. Yellow rape seared the eye. Round any corner one might put up a kingfisher or happen on a heron standing motionless. On windless days the arches of old stone bridges completed ovals with their reflections. My obsessive counting of mallard chicks, as many as eleven on one occasion, led Ralph to complain that I did not need to extend my family planning interests into the avian world.