Getting on the Bus

Getting on the Bus

‘We’re so grateful for the fact that they didn’t suffer at the end of their life’

‘Why didn’t they have a scan and a biopsy? It might have saved their life’

Sometimes it’s hard to know what ‘Doing the Right Thing’ is. Those questions could have been asked of me by relatives about exactly the same patient. In fact, they have been asked of me, repeatedly, about very similar patients. What is the difference between those patients, those relatives? Or is it me? Am I too nihilistic in my approach? Should I be more aggressive in my ordering of tests and treatments? Are their expectations reasonable or unreasonable?

We were taught, at medical school, a lot about pathology. We learned lists of causes for abnormalities of a thousand different, tiny systems. We learned rare, eponymous conditions that we should always be alert to, like constantly watching the skies for a comet that comes every few decades. We learned about things we must ‘never miss’ and about things we should ‘always think about’ – sodium, sarcoid, syphilis – all these things blend into – for me – a constant feeling of diagnostic unease.

But what do we learn about people? And how they think? And when we learn about ‘people’ do we include ourselves in that term? Or our colleagues and teachers? Somehow it felt as if we were a distinct group, separate from ‘people’ – our own foibles and fallacies were rarely addressed, and I could count on the fingers of one hand the times that my clinical teachers focused on the grey areas of medicine. Certainty was to be prized, uncertainty hidden. The diagnostic unease I spoke about earlier was to be pitied, a sign of weakness. If I didn’t know what was going on, it was because I just didn’t know enough, not because there wasn’t enough to go on.

The lectures – it was mostly lectures then, or hanging around on the wards – about people were not the popular ones. Epidemiology, psychology, sociology – these key areas of understanding – were not valued as highly as they should have been. We were used to facts. We survived on a diet of certainty and success and syndromes.

It’s taken me almost twenty years of clinical practice to realise – and be able to explain to patients, families, students, sometimes colleagues – that medicine is lots and lots and lots of grey. Not only are there far fewer certainties than I had first thought, but it is obvious that as clinicians we are affected by the same cognitive biases that influence and prime our patients and their relatives. We are human. Perhaps we should have listened a bit harder in those lectures about people.

And it is from ‘real’ people that most of the enduring lessons came. In our first year at medical school, we did something called (I think) a Family Project. This involved meeting someone who was experiencing a major life event, and following them every few weeks before writing a (horrifically naïve and judgemental, in my case) report about the experience. I was given the name and address of a woman expecting a baby. I used to get the 95 bus to visit her.

This is what I remember. She was the same age as me. She smoked a lot and I always smelt of it on the bus home. I tried to sound less southern when I talked to her. Her partner was in prison. I nearly told her two year-old this, inadvertently, because she had trusted me with information I didn’t realise was confidential. There was no carpet. On my first visit she apologised for not having any milk for tea. I didn’t realise that this was because she hadn’t felt well enough to go out and get her benefits. She said she nearly died during delivery and no-one listened to her when she told them what was happening. I wasn’t sure whether to believe her. When the baby was 4 weeks old I took it a present. She cried because it was the first present anyone had brought. I felt uncomfortable. I didn’t know whether to hug her or not. Once, her partner was there, unexpectedly, and asked me ‘who the fuck are you’. I dreaded getting the bus because I never knew what I might find.

None of my lectures had prepared me for any of this. I knew I should have valued it but frankly, I was relieved when it ended and I didn’t have to get the bus any more. I slipped easily back into my physiology textbooks, my anatomy practicals. For a while I thought that this experience was an aberration. It took me a long time to realise that this experience was the norm. The lack of context, the discomfort, the unease – this was what people were, not just syndromes to be learned or diseases to be studied.

It’s much easier to be certain than uncertain. It’s much more comfortable to surround yourself with the familiar than to seek out the unfamiliar. It’s much less hassle not to get on the bus. But for me, these days, getting on the bus means seeking out the diagnostic uncertainty in my own practice. Dealing with my own cognitive biases (I think they probably deserve a whole blog of their own) and recognising those of others – including patients and their families.

This means that ‘Doing the Right Thing’ is, unfortunately, different every time. It requires different thought, different communication, different approaches. It’s why I love what I do, and never get bored. And I realise – only now – it’s why I kept getting on the bus.

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9 thoughts on “Getting on the Bus

  1. Wow you really hit the nail on the head. Hoping to return to medicine soon after period of illness and it’s the people bit I really miss not the facts.My Daughter is about to start medical school. I wonder how much has changed in 20 years.

  2. A wonderful piece of writing that touched me immensely for its honesty, clarity, and humanity. Thank you for renewing my faith in medical practitioners but also reminding me that it is the uncertainties of life that make life worth living.

    Jim

  3. Wonderful reflections, Elin.
    So true that ‘doing the right thing’ is different every time, and that medicine is full of grey – primary care in particular has fifty shades of it.

    Our initial steep learning curve is learning about disease processes and treatments. After a few years, just as we are relieved that the curve is flattening, we look up and see new slopes we have yet to climb. The upper slopes are all about people – sick people, worried people, confused people, and of course our own selves.
    These upper slopes are cloudy, difficult to navigate, and are never truly mastered.
    But if we don’t spend our time trying, we may as well give up. Or become a chemical pathologist.

    I think some consultations merely require correct medical knowledge, applied in a linear fashion; a single diagnosis exists and we just have to follow a logical process to find and treat it. But other consultations are complex, with many possible twists, turns and outcomes, depending upon our approach. If anyone is interested, I described this further in my blog post ‘The non-linear consultation’ http://drjustincoleman.com/2014/01/14/the-non-linear-consultation/

  4. Reblogged this on Death and Taxes and commented:
    I agree Elin, the older I get the more I love uncertainty and humanity of those we care for. When I stumbled on Community Palliative Care I was terrified. Would I recommend the right drug, would I miss a spinal cord compression, would I look like I knew what I was doing? I’m still nervous before every visit but now absorb their lives, knowing often the best I can do is listen and navigate. Fabulous blog, thank you

  5. I spent twenty five years running programs for young families. This was after we moved to the US. My staff and I made hundreds of visits like this, and stayed with the family for a few months to 3-4 years. I know we made a huge difference to the lives and the futures of “our” families. I know our work was and is undervalued. Reading this piece makes me sure that I made the right choice when I decided not to go to med school, but to follow a different path. I so value your work, Elin, and now I know you would value mine.

  6. This reminds me of something written by John Diamond, before he died.

    “”But we expected more. Hell, we’d been promised more. Just as we’d learned, rightly, to expect that the political system could be arranged to provide a roof over the head and food in the stomach of all of us, so, we believed, could the medical system be arranged to give us all health and happiness. It was our right, dammit.”

    “And the medical establishment, flattered by all those pieces in the popular press describing the latest miracle cure which was just about —always just about — to arrive at the local surgery, joined in with the celebrations and connived with the scam. Indeed, if the boom in alternative medicine is anybody’s fault it’s that of orthodox medicine. It was the orthodoxy -helped by the media and our own vanity – which allowed us to believe that we could all be healthy and happy, that there was a pill for every problem and that if we died too early or too painfully it was an act of some agency other than capricious old God.”

    The fact is that disease classification, especially anything to do with the brain, is very crude indeed. Diagnosis is correspondingly crude. That’s nobody’s fault. It’s too complicated to understand. But I do think it would be a good idea if people admitted their ignorance a bit more openly.

  7. I really enjoyed reading your blog. It really brought back to me the discomfort I also felt as a young inexperienced medical student, at having to grapple with real people with their real problems. As you say, reality is so much greyer than the books. Indeed, the range of our greyscale clearly increases with age and experience. Looking forward to your next piece of writing

  8. Great blog, by the way. It seems that hospital doctors have more in common with GPs than perhaps they realise (or even like to realise). If you want to read more about this kind of thinking would highly recommend Peter Tate’s “The Other Side of Medicine” which I read as a trainee, where he describes the “swampy low lands of general practice uncertainty” compared to the lofty mountain tops of high-powered “proper diagnostic, curative medicine/surgery”.

    http://www.amazon.co.uk/Other-Side-Medicine-Peter-Tate/dp/1846191548
    (or you could just keep following @mellojonny!!)
    Looking forward to the next blog

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