It was cold on the scooter going back into
London, but I survived without too much trauma; and London has a warmth all its
own with millions of people breathing, living and heating up their flats and
houses. It was a relief to know I was almost home. Although the temperature was
still sometimes in low single figures and there could be frost on the roads
late at night and early in the morning, at least it had not rained on my
journey back from Plymouth.
Our flat was within walking distance of
King’s, 20 minutes through Stories Lane, onto Grove Lane and then Champion
Grove, past Dulwich railway station opposite the Salvation Army’s William Booth
Memorial College onto Denmark Hill. So Jan had been walking to work. But with
me back, on most mornings we took the scooter, which behaved itself in all
weathers, and was easy to park at the Med School, and in the road outside our
flat. We got into some sort of routine; and it was such a relief to be back
home with the one I loved.
Lectures continued, as did clinical casework
followed by ward rounds and outpatient clinics under close supervision of
registrars and occasionally consultants. In clinic, the idea was that we
‘clerked’ a patient referred by a general practitioner or from another clinic.
That is, we went through the history, clarifying details and did a focussed
examination, reporting a short synopsis of our findings. The registrar would
then double check our findings, and discuss treatment options with the patient.
Consultants did not see all the patients, but if there was anything tricky,
they were called in. Most registrars were easy to work with, and I rarely ran
into any sort of conflict, though several of my colleagues reported running
battles. You have to learn to do some strange things as part of the human body
examination, and it was in one of the outpatient clinics I first learned how to
do a rectal examination and interpret the findings. The headed letter from a
local doctor said cryptically “Abdomen: please see.” I took the history of
occasional rectal bleeding (noted especially when our patient had been
constipated), went through a history related to other systems in the body, and then
reported my findings so far. The registrar sought permission from the patient, donned
a glove, and then did his examination. There were some small haemorrhoids, and
he thought I should feel them. I put on a glove, used the lubricant provided,
and followed instructions trying hard to focus on the objective rather than the
feel, or the possible discomfort for the patient. Yes, I could feel the
fullness in two places roughly at 4 o’clock and 11 o’clock (that is how it is
described). I drew a diagram in the notes; the registrar nodded and began to
discuss possible treatment strategies with our patient, now upright with his
dignity returned. You cannot be squeamish in medicine, but sometimes it takes
practice to remove extraneous meanings, and focus on the main game. I will
always thank that registrar who passed on the phrase: “If you don’t put your
finger in it, you may put your foot in it”. Yes, later we laughed over the
phrase, but I never forgot it. Some years later, in general practice, there was
to be one spectacular example where a senior colleague had prescribed a cream
for his patient’s rectal soreness and bleeding, but had not done an
examination. When his patient came to me a few days later with bleeding that
was worse rather than better, I could actually feel the edges of the rectal
tumour causing the problem, and then saw the fresh bleeding from my gloved examination.
He was referred immediately to a local surgeon and operated on within days; he
survived.
So, medicine is a practical art. Read about descriptions
of illness in isolation and you may forget. Even reading about other people’s
case examples, the stories may become blurred over time. “See one; do one” and
you rarely forget. Take some responsibility in a clinical situation, be part of
finding out about the history and symptoms, find a problem during an
examination, and you never forget.
I suppose this is why I found parts of the early
psychiatry training so frustrating. I can understand that perhaps a therapist
in a deep and meaningful psychotherapeutic relationship with a patient, might
not want some ignorant student saying stupid things to their patient or
dismissing the symptoms as incomprehensible and therefore not real. But I had
always been fascinated by the workings of the mind, had begun to read widely
about psychiatry and its history, and thought I was ready to handle it. Perhaps
that is when a student is at their most dangerous. After all, as we all know, a
little knowledge can be a dangerous thing.
But ward rounds at King’s felt contrived. We
rarely met with the consultants; they kept their input to the controlled
environment of formal lectures. A small group of us would sit in silence, while
a registrar rehashed the symptoms with their patient, keeping it relatively simple
and working towards a diagnostic formulation. We were sometimes allowed to ask
a single question directly of the patient, but anything considered unrelated or
stupid was immediately dismissed by the registrar. The phrase: “You don’t have
to answer that question” was in frequent use. I get it; the primary aim is
always to first do no harm (‘primum non nocere’). But the process felt so
stilted. The alternatives were limited in the 60s. There were a few one-way
screens in use, but the use of live video from one room to another was
something in the realms of fantasy. It took an awful lot of very expensive
equipment to make films with any sort of audio recording. Admittedly, there
were round table discussions with consultants that led into psychoanalytic realms,
but these were infrequent.
One exception stands out in my memory. I had
been assigned to go to the Belgrave children’s hospital with one other
colleague and watch some play therapy. The two of us sat in a darkened room
behind a screen that obscured more than it revealed. Neither of us was
enamoured to be there, and we talked of anything but psychiatry. The view
changed as the lights in the therapy room were turned on; clever! A child of
about 6 was escorted by a slightly frumpy woman to a sandpit, which he entered.
The lady, whoever she was, sat on a stool by the pit and said nothing. The
child played, only occasionally looking up at the woman. A bit more confidant,
he began to describe some of the action. Perhaps describe is to strong, as what
he actually did was to comment on the action, factually, not using any feeling
words or explaining what he though was going on. There was a car crash between
two cars repeated again and again. Then a mountain of sand was smashed by a toy
aeroplane. The plane was taken out of the pit and flown around the doctor’s
head and then back into the pit. The doctor did not flinch. No comment was
made. As the process evolved, the child directed the doctor to hold an object;
that was then retrieved to be used in the next scenario.
We watched perplexed. A couple of times we
looked at each other, asking quietly what it was all about, and then checking
our watches. Would this boring torture never be over…?
As the process evolved, the relationship
between doctor and patient warmed. The child began to ask questions that were
answered briefly and gently. Sometimes the doctor would gently ask the child
what they thought the answer was to their own question. The play was never
directed, but the violence disappeared, the random nature of the actions began
to become some sort of repeated story.
The kindly doctor finished the session,
suggesting a further one the next day. The boy looked pleased. A few minutes
later she appeared in our darkened room, flicking the switch on the lights. “So
what did you make of that?” “Could you make any sense of it?” “Did you gain an
impression of what this boy was feeling?” “Would you like to speculate on what
each bit of the action in our session meant?” And when we fumbled for words and
stumbled through some half-baked responses, she very gently began to describe
what she thought had been happening.
The background situation, of course, was
something I would come to find quite common. The boy was the older of two
siblings who had begun to hurt his younger brother. The parents were at war,
and our boy had seen repeated severe violence in the home culminating in a head
injury necessitating hospitalisation for the mother. The boy had been bullied,
and had threatened in a 6-year-old way to kill his father. This had prompted
referral.
Our doctor matched each element of the
session to a piece of the history. In addition, she began to describe the
emerging relationship between her and the boy, his initial fears, his need for
her to respond to threat in a non-violent way, his testing of the emerging
bond. She made complete sense of the session mirroring the outside world,
talked about something called ‘transference’ (as if we had been taught all
about it), and discussed the beginning approach to healing through helping the
child to make sense of the world of sand play as a bridge to making sense of
the outside world. She described possible interventions she might make over the
next few sessions.
I was gob-smacked. How could you get so much
out playing in a sand pit? How did begin to learn about working with children
and what to do but also what not to do, as well as pacing the planned therapy?
I thought of not much else for days. I discussed the session and my responses
with one of the consultants back at King’s, Gordon Stuart Prince. He smiled
benignly, quietly suggesting that not only did I have some medical exams to
complete, but then, even if I got into psychiatry, I might have to learn to
walk before I could run. He was right. In fact, for many reasons, it was to take
me 5 years before I became serious about child psychiatry as a career, and then
a further 5 years before I could ‘run’.
I believe the ‘lady in the room’, was Eva
Frommer, at the time a consultant child psychiatrist at St. Thomas’s Hospital
in London, and author of Clinical Child Psychiatry (Heinemann, 1972). Our paths
never crossed again, yet I have never forgotten her influence in my life.
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