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Developing judgment, not being judgmental
Perspectives
The art of medicine Developing judgment, not being judgmental
Martin Bureau/AFP/Getty Images
See Editorial page 90
108
At the age of 24 years, rather late in the day, I decided that I wanted to become a doctor. More than the usual obstacles stood in my way. A greater hurdle than the immense competition and scarcity of available places at medical school faced by most aspiring UK medics. For I didn’t have a single A level in science, let alone four good grades in these subjects, having given them up in favour of humanities subjects at school. And although I had already been to university, it wouldn’t help. I might have gained a good degree in English Literature, but that would be useless to me in my quest to become a physician. Or so I thought. Years in undergraduate medical training did nothing to shift my conviction, held shamefully quiet, that I was lacking something important. Even when I had crammed my way through enough chemistry, maths, physics, and biology that my teachers couldn’t tell the difference between me and my more naturally scientific peers, even when I had painstakingly dissected an entire human cadaver and learned to name each part that I threw into the bucket of remains, even when taking my place in a circle of students standing around a hospital bed while a consultant taught us the essential things that can only be learned at the bed side, I felt that I was radically ill-equipped. That my white coat should bear a sign, a dunce’s emblem, something to mark me out from the others as an imposter. If I had been brave enough to share my fear with one of my seniors or even to name it
to myself, I would have said that what I felt I was missing was judgment. And without it, what good would I ever be as a doctor? Without judgment, how was I to manage that most basic of clinical skills, the forming of a diagnosis? I could press my stethoscope to a patient’s chest, listen, and even describe to my waiting consultant that what I heard was whispering pectoriloquy. I could look at a set of blood results and know that the haemoglobin was low, or the potassium high. I could feel when someone’s liver was too big and decipher abnormalities by simply looking at a patient’s hands. I could read useful things from an ECG trace. But what I couldn’t do was work out what all this information meant. I couldn’t seem to learn how to disregard what didn’t matter, to pull together all the needles from all the haystacks, to arrive at a diagnosis, the crucial start-point for getting a patient better. Lacking in judgment I might have been, but it certainly didn’t stop me being judgmental. Late one night, when I was a junior doctor working in an Accident and Emergency Department, a man was brought in whom none of us doctors wanted to see. Wheeled in by one of the paramedics, this old man was cursing. He smelled of urine and old booze. And he was covered in blood. There were bruises on his arms and lots of small cuts all over his face and neck. He was crying bloody tears into his beard. As one of the nurses went to get him into a hospital gown, we all did our best to make ourselves scarce. What would we learn from someone like this? He was drunk and messy and would probably be verbally abusive. I can’t remember what my callow thoughts were exactly, but they were not worthy ones. But somehow it was me who ended up seeing this patient. The nurse had taken the man into a special washing room we had in the Accident and Emergency Department. There was an old dentist’s chair bolted to the floor that could be reclined against a basin and the man sat back in it, his big bloody head cradled in the ceramic curve, his eyes shut as the nurse ran warm water from a shower head attached to a long hose over his hair and face and neck. The tiled floor dipped down towards a dark drain and red water ran into it. It might have been a rudimentary barber’s shop. It put me momentarily in mind of the Barber of Seville. I took the shower head from the nurse and directed the water over my patient’s head. He closed his eyes with the ease of the warmth and I looked at his face. All was silent except for the soft splash of the water. And soon, he began to talk to me. Jeremy was not as old as all that. He had been a lawyer and had until recently lived with his family in a nice big www.thelancet.com Vol 385 January 10, 2015
house in a genteel part of town. I listened and ran the water over his head and the water running down the drain wasn’t red anymore but ran paler. Life had been good until Jeremy’s son had started hanging out with a new group of friends and Jeremy and his wife discovered he was taking heroin. One day, Jeremy’s son injected too much heroin and he died. Seeing the water run clear, I moved my patient from the chair and put a towel round his shoulders and we found a clean, dry cubicle where I settled him down and began the slow process of sewing up his cuts, one by one. After his son died, Jeremy told me, he and his wife fought and soon she left. And then he started drinking and couldn’t stop and eventually he lost his job and then his house. Jeremy had been on the streets for almost a year. And that night, sleeping on the pavement, he had been woken by a group of young men, the same age as his lost son, who had kicked him and cut him with their penknives. The shame I felt at listening to Jeremy deepened as his story progressed. What had I assumed when I first saw him coming into the department that evening, painted with blood? That he was a loser, someone worthless? What kind of doctor was I to have written him off in this way? I should have known better, not just because I was older than my peers but surely also because of my degree in English Literature. I thought of Magwitch, Charles Dickens’ munificent convict in the marshes, I thought of Macbeth and Medea committing their crimes of regicide and child-killing. I thought of the eponymous protagonist in Lionel Shriver’s We Need to Talk About Kevin which I had just finished reading. None of the great characters in literature were clean or simple or saccharine-coated. People were more interesting than that, and more difficult. Since that evening in Accident and Emergency more than 10 years ago, I have often reflected on the mutually beneficial relationship between enjoying literature on the one hand, and doctoring on the other. And it’s not just, as people often imagine, that patients provide one with endless writing material, an infinite variety of characters from which to draw. I think there is something in the practice of reading and trying to write about true and varied characters that forces one to listen to people in a different way, and this includes in a clinical setting. More openly, with a greater ability to embrace ambiguity and uncertainty. And, in a clinical setting, I like to believe that this confers a benefit for the patient as well as the doctor, that not only is one more likely to understand what a patient is suffering by taking them on their own terms, but that there is a therapeutic value in so doing, that the sincere listening of a good doctor can fall upon a patient like a kind of balm. In my case, truly hearing my patients and not being presumptuous about them is still a work in progress. Last week, I performed a short, local anaesthetic procedure www.thelancet.com Vol 385 January 10, 2015
Petworth House, Sussex, UK/The Egremont Collection/National Trust Photographic Library/Derrick E Witty/Bridgeman Images
Perspectives
Macbeth and the Witches (1793–94) by Henry Fuseli
on a woman in her nineties who was in the late stages of dementia. She was accompanied by an employee from her nursing home, and also by her husband. My patient seemed catatonic, didn’t seem to notice the pain of the local anaesthetic. She was not able to communicate with me in any way as I operated on her. What was the point in this? I thought. Why was I performing surgery on a person who clearly had no quality of life and would probably soon die. As I wrote my op note, I looked up at her husband and, in a knowing way, said to him, “It must be awful for you”. I was thinking of assisted dying, how his wife was the embodiment of why it should be available. With bright eyes and a completely steady voice he responded. “Oh no, dear, not at all! I go and visit her every day. And, when we are alone, she knows exactly who I am. And we hold hands and we share things. We still love each other, you see.” And I felt that old shame, the one I had experienced so long ago after I had talked with Jeremy in Accident and Emergency. And I was reminded of how much work I still have to do, how much reading and writing and listening, before I can even begin to think I have started fully to embrace and appreciate our common humanity.
Gabriel Weston Frimley Park Hospital NHS Foundation Trust, Frimley GU16 7UJ, Surrey, UK Gabriel Weston is the author of Dirty Work: A Novel (2013) and Direct Red: A Surgeon’s Story (2010).
109
The art of medicine Developing judgment, not being judgmental
Martin Bureau/AFP/Getty Images
See Editorial page 90
108
At the age of 24 years, rather late in the day, I decided that I wanted to become a doctor. More than the usual obstacles stood in my way. A greater hurdle than the immense competition and scarcity of available places at medical school faced by most aspiring UK medics. For I didn’t have a single A level in science, let alone four good grades in these subjects, having given them up in favour of humanities subjects at school. And although I had already been to university, it wouldn’t help. I might have gained a good degree in English Literature, but that would be useless to me in my quest to become a physician. Or so I thought. Years in undergraduate medical training did nothing to shift my conviction, held shamefully quiet, that I was lacking something important. Even when I had crammed my way through enough chemistry, maths, physics, and biology that my teachers couldn’t tell the difference between me and my more naturally scientific peers, even when I had painstakingly dissected an entire human cadaver and learned to name each part that I threw into the bucket of remains, even when taking my place in a circle of students standing around a hospital bed while a consultant taught us the essential things that can only be learned at the bed side, I felt that I was radically ill-equipped. That my white coat should bear a sign, a dunce’s emblem, something to mark me out from the others as an imposter. If I had been brave enough to share my fear with one of my seniors or even to name it
to myself, I would have said that what I felt I was missing was judgment. And without it, what good would I ever be as a doctor? Without judgment, how was I to manage that most basic of clinical skills, the forming of a diagnosis? I could press my stethoscope to a patient’s chest, listen, and even describe to my waiting consultant that what I heard was whispering pectoriloquy. I could look at a set of blood results and know that the haemoglobin was low, or the potassium high. I could feel when someone’s liver was too big and decipher abnormalities by simply looking at a patient’s hands. I could read useful things from an ECG trace. But what I couldn’t do was work out what all this information meant. I couldn’t seem to learn how to disregard what didn’t matter, to pull together all the needles from all the haystacks, to arrive at a diagnosis, the crucial start-point for getting a patient better. Lacking in judgment I might have been, but it certainly didn’t stop me being judgmental. Late one night, when I was a junior doctor working in an Accident and Emergency Department, a man was brought in whom none of us doctors wanted to see. Wheeled in by one of the paramedics, this old man was cursing. He smelled of urine and old booze. And he was covered in blood. There were bruises on his arms and lots of small cuts all over his face and neck. He was crying bloody tears into his beard. As one of the nurses went to get him into a hospital gown, we all did our best to make ourselves scarce. What would we learn from someone like this? He was drunk and messy and would probably be verbally abusive. I can’t remember what my callow thoughts were exactly, but they were not worthy ones. But somehow it was me who ended up seeing this patient. The nurse had taken the man into a special washing room we had in the Accident and Emergency Department. There was an old dentist’s chair bolted to the floor that could be reclined against a basin and the man sat back in it, his big bloody head cradled in the ceramic curve, his eyes shut as the nurse ran warm water from a shower head attached to a long hose over his hair and face and neck. The tiled floor dipped down towards a dark drain and red water ran into it. It might have been a rudimentary barber’s shop. It put me momentarily in mind of the Barber of Seville. I took the shower head from the nurse and directed the water over my patient’s head. He closed his eyes with the ease of the warmth and I looked at his face. All was silent except for the soft splash of the water. And soon, he began to talk to me. Jeremy was not as old as all that. He had been a lawyer and had until recently lived with his family in a nice big www.thelancet.com Vol 385 January 10, 2015
house in a genteel part of town. I listened and ran the water over his head and the water running down the drain wasn’t red anymore but ran paler. Life had been good until Jeremy’s son had started hanging out with a new group of friends and Jeremy and his wife discovered he was taking heroin. One day, Jeremy’s son injected too much heroin and he died. Seeing the water run clear, I moved my patient from the chair and put a towel round his shoulders and we found a clean, dry cubicle where I settled him down and began the slow process of sewing up his cuts, one by one. After his son died, Jeremy told me, he and his wife fought and soon she left. And then he started drinking and couldn’t stop and eventually he lost his job and then his house. Jeremy had been on the streets for almost a year. And that night, sleeping on the pavement, he had been woken by a group of young men, the same age as his lost son, who had kicked him and cut him with their penknives. The shame I felt at listening to Jeremy deepened as his story progressed. What had I assumed when I first saw him coming into the department that evening, painted with blood? That he was a loser, someone worthless? What kind of doctor was I to have written him off in this way? I should have known better, not just because I was older than my peers but surely also because of my degree in English Literature. I thought of Magwitch, Charles Dickens’ munificent convict in the marshes, I thought of Macbeth and Medea committing their crimes of regicide and child-killing. I thought of the eponymous protagonist in Lionel Shriver’s We Need to Talk About Kevin which I had just finished reading. None of the great characters in literature were clean or simple or saccharine-coated. People were more interesting than that, and more difficult. Since that evening in Accident and Emergency more than 10 years ago, I have often reflected on the mutually beneficial relationship between enjoying literature on the one hand, and doctoring on the other. And it’s not just, as people often imagine, that patients provide one with endless writing material, an infinite variety of characters from which to draw. I think there is something in the practice of reading and trying to write about true and varied characters that forces one to listen to people in a different way, and this includes in a clinical setting. More openly, with a greater ability to embrace ambiguity and uncertainty. And, in a clinical setting, I like to believe that this confers a benefit for the patient as well as the doctor, that not only is one more likely to understand what a patient is suffering by taking them on their own terms, but that there is a therapeutic value in so doing, that the sincere listening of a good doctor can fall upon a patient like a kind of balm. In my case, truly hearing my patients and not being presumptuous about them is still a work in progress. Last week, I performed a short, local anaesthetic procedure www.thelancet.com Vol 385 January 10, 2015
Petworth House, Sussex, UK/The Egremont Collection/National Trust Photographic Library/Derrick E Witty/Bridgeman Images
Perspectives
Macbeth and the Witches (1793–94) by Henry Fuseli
on a woman in her nineties who was in the late stages of dementia. She was accompanied by an employee from her nursing home, and also by her husband. My patient seemed catatonic, didn’t seem to notice the pain of the local anaesthetic. She was not able to communicate with me in any way as I operated on her. What was the point in this? I thought. Why was I performing surgery on a person who clearly had no quality of life and would probably soon die. As I wrote my op note, I looked up at her husband and, in a knowing way, said to him, “It must be awful for you”. I was thinking of assisted dying, how his wife was the embodiment of why it should be available. With bright eyes and a completely steady voice he responded. “Oh no, dear, not at all! I go and visit her every day. And, when we are alone, she knows exactly who I am. And we hold hands and we share things. We still love each other, you see.” And I felt that old shame, the one I had experienced so long ago after I had talked with Jeremy in Accident and Emergency. And I was reminded of how much work I still have to do, how much reading and writing and listening, before I can even begin to think I have started fully to embrace and appreciate our common humanity.
Gabriel Weston Frimley Park Hospital NHS Foundation Trust, Frimley GU16 7UJ, Surrey, UK Gabriel Weston is the author of Dirty Work: A Novel (2013) and Direct Red: A Surgeon’s Story (2010).
109