Growing Into Medicine (19 page)

Many people believe that abortion should be freely available on demand, especially in the early weeks. In an over-stretched service, and an overpopulated world, this may be unavoidable. Most women have decided what they want and do not change their minds after
discussion. But I still believe the opportunity to consider how they might feel afterwards can mitigate later self-recrimination and depression. This sort of benefit is difficult to measure. I would say, ‘Yes you can have a termination, I will of course sign the form, but now let’s talk about it.’ Explaining that the woman did not have to justify her desire to end the pregnancy sometimes meant she was more able to discuss how she might feel about it afterwards. The idea that there was no good solution, only a least bad one, was helpful to some people. Certainly, if one could provide time during a routine clinic to let patients discuss their feelings, before or after the event, they found some relief. One of the letters I have kept in an envelope marked ‘Some of my most precious possessions’ is from a patient thanking me for spotting her overactive thyroid and also for having allowed her to discuss the termination she had chosen a few months earlier. That piece of paper is a token that I was sometimes the sort of doctor I aspired to be – one who could to some degree care for the body and the mind.

Many of the same arguments held for sterilisation counselling. The FPA had run vasectomy counselling clinics since 1968. I found the challenges fascinating. Often the request was made by a couple who, under the stress of a new baby, felt unable to cope; life had been thrown into total chaos. By choosing the safest method of contraception they could at least be in control of one aspect of their lives. But the operation is not reliably reversible and if they were still young, with perhaps only one child, their request prompted me to try to help them find another acceptable method, possibly an injection or implant, to carry them over the next few months. Once the immediate pressures had eased I was surprised how many couples decided they would like to keep the option of another baby open for a bit longer.

Another striking finding was the wish by many men to ‘do their part’. They felt that their wife had done her share by giving birth to the babies and it was now their turn. The fact that her fertility would end naturally, while his could continue into old age, had not usually been discussed between them. If they divorced or the wife died, the
man might want to marry a younger woman with no children of her own.

Men were appearing in clinics in greater numbers, both as doctors and patients. Sometimes a man, often angry, would arrive in the waiting room, causing confusion – but providing the possibility of an understanding that had been absent before. One patient told us repeatedly that she wanted to take the pill but as soon as we gave her a supply her husband threw them on the fire. After several visits I heard a commotion outside my door and he burst in.

‘What do you think you are doing, giving my wife all these pills?’

‘Well, she would like to stop having any more babies for a while,’ I murmured, reaching out to save a family photo from the hands of a three-year-old. Four of their six children were rampaging round the room, which I shared with a GP who had left many of his belongings within child’s reach.

‘What do you mean?’ he shouted. ‘I planned these children.’ Then under his breath he added, ‘Are you saying I can’t control myself?’

I was lucky to have heard him. ‘Do sit down and let’s talk about this,’ I said.

He sat reluctantly, taking a child on his knee. ‘I am man enough you know.’

I began to understand that he was using coitus interruptus and I was casting aspersions on his manhood by suggesting he was not very good at it. In that part of the country it was an important status symbol for a man to be able to satisfy his woman and then pull out.

‘Of course you are being as careful as any man could be,’ I said. I went on to explain that, however careful he was, a drop of semen could escape ages before he reached his climax, and that this was nothing any man could control. He relaxed, and after I had admired his fractious children for some time his wife was allowed to go home with some more pills.

I do not claim any particular insight into these findings, for they are well recognised by those working in clinics and probably by every agony aunt in the country. For me the effort to understand each individual and each couple, to see where they fitted or did not
fit into emerging patterns, was satisfying. As I began to understand some of the complex feelings, both conscious and unconscious, that affect our sex lives, I became a strong advocate for what detractors called a duplicated service.

Choice for patients has become a political slogan in this century. Despite my emphasis in the last chapter on the importance of choice in relation to contraception and to the work/life balance, I feel it is often overrated when we are ill. Most of us want a doctor we can trust, who has personal contacts with consultants working in a good enough hospital within a reasonable distance. We are not usually in a state to weigh all the pros and cons of treatments, consultants and services. But when it comes to our sex lives the situation is different. Sex is messy, both physically and often emotionally. We get carried away and do not always make sensible decisions. Not everyone feels able to talk to their regular doctor, who might have cared for them as a child, the ultimate authority figure called in when the parents could not cope. When I am ill I want my doctor to consider me a sensible person, so that he will take my symptoms seriously and believe what I have to say. But sex puts us in touch with a silly side of ourselves when we often make mistakes. For these reasons sexually transmitted disease clinics have always been open to everyone, with no requirement for referral from another doctor. A special parliamentary statute protects confidentiality in these clinics. In various editorials I have argued strongly that family planning clinics should be treated in the same way, but this has never happened.

Over the years there have been many changes. General practices are larger with many more women partners. Sex is more openly discussed in society. Pharmacists and nurses play a much bigger role in the provision of services and advice, and many supplies are available on the net. But despite this liberalisation unplanned pregnancies still occur in large numbers. In 2009, 189,000 abortions were performed in England and Wales. I hope that, whatever the structure of the future NHS, designated family planning clinics will not
wither away. The importance of a sign over the door that says, in effect, ‘We are interested in sex’ cannot be exaggerated.

Once GPs began providing FP advice for their patients the nature of trainees in the clinics changed. Hospital doctors too were realising that they needed expertise in this field. I was interested in the developments that were taking place in training for general practice and the different ideas about how to analyse the consultation. The fashion at the time was to break the interaction into tasks, an approach that seemed very limited for it did not help the doctor to notice a patient’s unspoken communications. For instance, one of the tasks was to explain the pros and cons of any treatment. As one conscientious family planning trainee went through all the possible side effects of the pill I saw the patient’s eyes glaze over. After several minutes I intervened.

‘You are clearly still anxious. I wonder what is worrying you?’

Relieved, she turned to me and said, ‘I am worried that it may be difficult for me to have a baby when I am ready.’

The effect of different methods on future fertility must have been the only subject that had not been mentioned during the exposition.

I was lucky to be asked to take part in a trial weekend designed to develop guidelines for training the trainers in family planning. Together with Gill Cardy and Elizabeth Gregson we planned the course, which was strengthened when Gill’s husband Ian, a GP, joined us. We enlisted the help of an educationalist who was adamant that a residential weekend should include group work and a progressive rise in the demands made on the participants. He explained that they needed to be stretched but that the level of anxiety must not become overwhelming.

At this time the concept of recording live consultations with patients, after asking their permission, was fashionable. We thought it important, as tutors, to share our own videos. I was horrified to see that I appeared to wave the clinic notes in front of my face as a shield! I hope the camera had exaggerated this effect but at least
when I showed it on the course I could not pretend to be setting a perfect example.

The style of one northern GP was particularly interesting. He appeared to break all the rules, hardly looking up as the patient entered the room. He started the consultation with a string of questions. I felt myself getting hot with embarrassment as I watched his interest confined entirely to his notes. However, after a few minutes he put down his pen, sat back in his chair and looked up. ‘Now, tell me about the problem.’ His expression was transformed as if, having first dealt with the detritus that lay between them, every cell in his body was at the patient’s disposal.

Through the seminars run by the Institute of Psychosexual Medicine, I had experience of working as a member and also leader of various groups. Every scrap of judgement I had acquired was needed as the course progressed. Unfortunately my co-tutor Elizabeth Gregson was taken ill. My own group was working well and I was happy to leave it knowing that my journal colleague Elizabeth Forsythe and Heather Montford, both doctors with great experience in the field, would make sure it continued to run smoothly.

The same could not be said for the group that had been without a leader for a while. By this stage we were engaged in three-way role-play with participants taking the parts of doctor, trainer and patient. I walked in to discover one member lying on a sofa feeling poorly and the floor taken by a GP trainer telling the rest how the consultation should be conducted. The whole point of the session was to simulate the experience of such a consultation, not to give a lecture about how it should be done. The only way I could restore the spirit of the exercise was to introduce a new prepared case. I asked the doctor who had been showing off to play the part of an anxious and embarrassed man sent to the clinic by his wife to collect condoms.

Our format was adopted for several years by local authorities and by John Guillebaud, who ran such courses for the Margaret Pyke centre, an independent organisation. Working as a tutor with Heather on these courses was great fun and we became very good
friends. The first time we cooperated we prepared a series of imagined scenarios, giving all the patients the names of birds. We can still remember Miss Dove who was a shy soul unable to voice her problems, and Mr Peacock whose flamboyance hid his deep uncertainty about his sexuality.

One unexpected effect of this role-play was shown by some doctors, especially those trained in Asia, who were very authoritarian when playing the doctor’s role. This behaviour easily antagonised the group. When such doctors were asked to put themselves in the place of a pregnant sixteen-year-old we discovered they were not lacking in sympathy. Quite the reverse; they showed a deep and touching empathy with the patient’s predicament, becoming hesitant, embarrassed and vulnerable. The original impression, caused by cultural expectations on their part, and probably by many of their patients, was that the doctor should always be the one to give advice and make decisions. It has taken all of us a long time to learn that in the contraceptive field such an approach is seldom in the best interest of the patient.

The experience reinforced the lesson I had learned when I was a hospital resident with doctors from different cultures: that individuals are more important than cultural stereotypes. Now, in old age, I take great pleasure in meeting people of all ages, social status and cultural background: but if I base my judgements of them on first impressions and superficial differences I can still make bad mistakes.

13

Body/Mind Doctoring

The body/mind split has been laid at the door of Descartes. I confess I have not read him but, like a jackdaw, I pick up secondhand shiny objects and ideas. Apt quotations have a particular attraction. I collect them in my ‘Jackdaw book’, where I find a scribbled note about Descartes. Apparently, in his determination to refound human knowledge, he said that the mind and the body were distinct substances. In this way he could reconcile the death of the physical body with his belief in the immortality of the soul.

Although Descartes died in 1650, his thinking still has a profound effect. Only now, with the development of detailed brain imaging, is it possible to begin to grasp the connections between these two aspects of a human being. I am excited by Iain McGilchrist’s book
The Master and his Emissary
. He provides a detailed review of the results of recent studies in brain imaging, and is particularly interested in the work of the two sides of the brain. Their different tasks, and in particular the intimate ways in which they communicate with each other, provide both a factual and a metaphorical basis for seeing each person as a unit.

In the day to day work of doctors, the struggle to gain such insight is only just beginning. I believe that the potential for the body and the mind to interact is present at every level: the single cell, the tissues, the organs and the self. But it is difficult to assimilate that belief into my relationships, personal or professional.

One of the problems is that scientific medicine has advanced so rapidly. Pasteur discovered microbes and my ancestor Lord Lister
developed some techniques to combat them. Alexander Fleming noticed an absence of mould and discovered penicillin. Crick and Watson unravelled the secrets of DNA. In quite a different room Freud laid his patients on a couch and explored the unconscious.

Medical science has scampered into specialities that keep dividing like an overactive amoeba. As the volume of knowledge expands, the old saw fulfils itself, and experts know more and more about less and less. Such division is the outcome of analytical activity, located in the left hemisphere of the brain. McGilchrist believes that, during the development of the western world, this aspect of humanity has become too powerful.