Heart Beat: There is a voluminous literature on the doctor-patient relationship. Some would maintain that even more is written about its absence. Thankfully I have only once been a patient and when I was, I was a bad one. I do not propose to dwell on this in the hope that those caring for me then will have forgotten about it.
I will, however, talk about how it was for me on the other side of the divide. There were no meaningful textbooks or primers on how to relate to patients. Observation and instruction by our teachers had contributed much, but at the end of the day the individual doctors and patients defined their own relationships.
As an intern you were the first port of call. You took the initial comprehensive history, including previous medical history, family history and social history, and anything else relevant. Sometimes the history was delivered by a wife, acting as if the husband was not there or was bereft of the power of speech. In this latter instance it was usually accompanied by observations like "He drinks/smokes too much. He never takes any exercise."
En passant, is it any wonder that the women live longer? The initial history, examination and ordering of tests seldom took less than three-quarters of an hour. On a busy unit with many admissions this made for a very long day. Relatively minor complaints and injuries could be processed fairly quickly, but on the other hand very sick and complicated patients took a long time, and we were only learning.
In student days we took histories and examined patients. Now we did the same, but now they were our patients and we had to get to know them. We were between them and the physicians and surgeons who were in charge. We hopefully learned, as Edward Goodman said, "It is a distinct art to talk medicine in the language of the non-medical man." Maybe this was the development of a bedside manner. We learned also to avoid wherever possible the pitfalls for the unwary.
I found that about 10 per cent of patients gave a straightforward, unambiguous description of their condition. A further 40 per cent gave a totally inadequate history, some because they were incapable of so doing, some suppressing salient points through fear. In this group came the frankly uncommunicative patients and the smart ones: "What's the matter?" "That's your job to find out."
About another 40 per cent were garrulous, often in the extreme, and the path to diagnosis was strewn with red herrings and marked by culs de sac and diversions. Hypochondriacs belonged here, if there was indeed a nugget of illness buried in the verbiage you had to dig deep to find it. This often required more patience than we possessed.
In the final 10 per cent, the history was provided by paramedics or relatives, with treatment coming first and history coming later.
We learned, as Sir William Jenner pointed out, "Never believe what a patient tells you his doctor has said." We learned to deal with exaggeration and suppression and we learned how to recognise and be gentle with fear. We found it less easy to deal with anger. Fear, helplessness and uncertainty made some patients, and indeed relatives, angry. "In time we hate that which we so often fear." (Shakespeare, Anthony and Cleopatra.)
Such anger is often vented on the carers and even with understanding of its cause is most difficult to handle. Tired overworked staff have to swallow hard to rationalise abuse and anger. We had been taught and had observed the perils of becoming too closely involved with the trials and terrors that sickness visited on some.
Throughout my career this has proved extremely difficult especially when dealing with children. We had to learn to deal with disappointment, the pain of fearsome diagnosis and the certainty of death. These were difficult tasks for young people and, in hindsight, of course, there were times when you might have done better.
You learned also that you did not have rapport with everyone. Not every patient or family liked you. The converse also held true.
Having started in July, the summer just disappeared, we had lots of work and very little play, but we had an increasing appreciation of our role within the hospital. We became used to being called at night and often running through a darkened silent sleeping hospital, and realising that in the first instance you were "the man".
You entertained your doubts and worries and learned all the time. That first August was quiet for me, but things were about to change. A vignette of that August remains with me. I was sitting in the residence on a warm sunny afternoon, reading the paper, the surgical registrar slept in an adjacent chair. The door opened to admit one of my lady fellow interns. The registrar awoke, looked around and said "there she is Maurice, say it to her face". To this day she does not accept my protestations.
I was removed from the casualty roster, as it was explained to me that I would be first on call for the post-operative heart operations and would be required on those nights to sleep in the intensive care unit, such as it was then. This often followed a very long day in theatre. It was for me the start of my involvement in the branch of surgery that was to become my life. In retrospect, I loved every minute.