Freedom for Tooting Part 1: The second worst job

I started the undergraduate clinical course at St George’s in September 1977, which necessitated a sensible haircut and the purchase of a tie. My grandmother bought me a stethoscope. We were provided with white coats that were the right size for nobody. Doctors’ ties and white coats were already known to be common vectors for cross infection in hospitals, but it was some decades before they disappeared from hospital practice. Students were allocated rotating attachments to a variety of clinical firms, each led by a consultant.

Learning clinical medicine by spending time with patients was exciting. It was what I had wanted to do for years, and it did not disappoint. Although much of the pre-clinical course had been boring, it did equip us with an excellent grasp of human biology. In retrospect, we had been taught very little about scientific method or epistemology or the social implications of medicine. Many gaps of this type were filled through close contact with clinicians and clinical academics, some of whom had fine intellects. A wide breadth of scientific knowledge was applied to all kinds of human troubles. If I am truthful, there was a real buzz about moving around the bustling hospital environment looking a bit like a doctor. Teaching was predominantly at the bedside or ward offices in small groups. When it worked well, there was a kind of intense Socratic learning process. Unfortunately, some doctors saw it as an opportunity to bolster their fragile self-esteem, and instead of teaching, engaged in ritual humiliation of medical students.

The major downside of the clinical course arose from the fact that by temperament I am a physician, and it rapidly became apparent that I did not particularly like any aspect of the surgical specialties. I am not saying this was necessarily the surgeons’ fault rather than mine, but, as far as I could see, one of us was definitely out of order. I found operations mind-numbingly boring, except for those unexpected moments when they became frightening because something was going wrong. British doctors, then and now, qualify with two bachelor’s degrees: one in medicine and one in surgery. Fifty percent of what I had to learn was surgical. My surgical-hesitancy was a distinct problem.

At around this time, Peter Cook and Dudley Moore released an album called Derek and Clive Live. Peter Cook was arguably the most important British comedian of the post war period, an extraordinarily talented man with a truly original wit and a serious alcohol problem. Derek and Clive Live was wildly popular at the time, and it was regarded as a transgressive masterpiece. Listening to it now, it sounds like sweary drunken ramblings. The first track is The Worst Job I Ever Had, and that became my label for surgery in general. The title was won in the face of stiff competition. In any normal life, warehouse man at Caters Supermarket in Catford would have been unassailably the worst job I ever had, but, in my life, it was relegated to second position. There were marked similarities between my two worst jobs.

I took the job at Caters straight after I left school. Several of my friends worked in the warehouse above the store on a Saturday. The warehouse staff stuck together because the meat counter harboured a group of decidedly unpleasant young men who existed in a macho subculture.  Just like many surgeons in the 1970s, the butchers at Caters were unemployable in any other environment, but they regarded themselves as the elite of the work place. They adopted a strutting, bullying stance to emphasise their superiority.  When they fell out with people, which was often, they would throw offal around the warehouse and at each other, leaving the resultant mess for others to clear up. Surgeons did not throw organs around, but surgical instruments, telephones and case notes did get thrown about by the more regressed amongst them. One senior surgeon at St George’s had been acquitted of stabbing someone in a road rage incident in 1967, despite the fact that he acknowledged in court that the knife was in his hand at the time. Another senior surgeon had ripped an X-Ray light box off the wall because something had irritated him. I do not think that any patients were present in either case, but I cannot be sure. In making a comparison, it must be said that the Caters butchers never expected anyone to call them Sir.

caters butchers add

Racism was evident in both settings, and guilelessly revealed by the perpetrators. I once asked Eric, one of the Caters managers, why there was not a single Black employee in the supermarket, despite the high proportion of Black people in the local population. At first he claimed that “they don’t apply for jobs here”. When I told him that a Black friend of mine had applied and had been knocked back, he said “well, you wouldn’t want them handling your food, would you?” I paraphrase. I cannot bear to write what he actually said. His unvarnished bigotry was shocking, even in those days when racist comments were broadcast as comedy on the TV and were offered as justification by embittered old people as they pushed their way to the front of bus queues. Unable to think of a suitably scathing riposte, I shook my head and walked away.

Early in the clinical course, I did an attachment with a urologist. I shall call him Piddle. He was obnoxious to us medical students, whom he called “the children”. He liked to declaim opinions that would make the editor of the Daily Mail blush.  The most charitable description of his manner with patients would be “patronising”. One day, two of us were sitting in his clinic when he assessed a Black bus driver in his fifties referred by his GP for treatment of Peyronie’s Disease. This involves the formation of a fibrous plaque in the penis, which consequently becomes bent when erect. It can be painful and it causes sexual dysfunction. Not surprisingly, it can have a major impact on relationships and upon self-esteem.

Mr Piddle conducted a brief examination and brusquely told the man that it was not a big problem and that there was no treatment. The latter was not entirely accurate, although the surgical treatment was quite problematic. The unfortunate man looked uncomfortable as he was quickly hustled out of the room. As the door closed, Mr Piddle turned to us and said “Blacks. The only thing they think about is sex, you know”. My colleague and I were shocked and just looked at him. I still feel ashamed that we failed to challenge him, just as I had lacked the presence of mind to effectively challenge Eric.

Racist sentiments were more frequently expressed in those days, but racism in the well-educated or the ignorant cannot be excused on the basis that everyone thought like that. Many people objected to racism.  Racist language caused arguments between pupils at my school, where there were only a few Black pupils. My parents would have no truck with racism, and our friends were ethnically diverse, which was not unusual. Hundreds of thousands of us attended marches and events organised by the Anti-Nazi League and Rock Against Racism to oppose the National Front, a far-right group,. What was different back then was that racists did not expect their unguarded remarks to have any adverse consequences for them. Those who rail against “political correctness” or “wokery” would take us back to that.

At Caters, my main role was to fill shelves, but sometimes I worked on the tills. Barcodes had not been invented, so the price of each item had to be entered into the till manually. Time passed extremely slowly. One day, Eric the racist manager placed a jar of coffee next to my till, just by the conveyor belt. He told me to leave it there and to ring it onto the  bill of alternating customers. If anyone challenged me, I was to say that it must have been left by the previous customer and that I had made an Understandable Error. By this means, he told me, takings could be increased and the chances that everyone would get an end of year bonus would improve. I did leave the jar of coffee in situ and I did make Understandable Errors, but they were in the opposite direction to Eric’s instruction. There was supposed to be a rigorous weekly audit of the till rolls to identify discrepancies, but none of my Understandable Errors never came to light, presumably because a truly rigorous audit would have revealed Eric’s outrageous scheme. Occasionally, customers would ask me why their weekly shop had cost less than usual and I would tell them that the manager was experimenting with redistributive retail.

The equivalent dishonesty amongst surgeons  of the 1970s was exploitation of the NHS to support private practice. Although many surgeons were devoted to the NHS, some hardly bothered to turn up for their NHS operating lists. They busied themselves in Harley Street while their NHS operations were carried out by the junior doctors that they were supposed to be training. I have always been a strong supporter of the principle that health care resources should be distributed on the basis of need, not the ability to pay. Consequently, I am opposed to private practice. I am sorry to report that private practice was yet another thing that I made little effort to challenge or subvert as a student, much as I railed against it privately.

The goods lift at Caters was noticeably unsafe, but it could only be operated by riding with the goods. It should not have been possible for the lift to move unless the safety doors were properly closed, but the lift had been tampered with so that they could be jammed, stalling the lift between floors. It was well know that this had been done to facilitate furtive sexual activity, an arrangement that involved the exchange of cash. The managers knew about the problem with the lift and the reason for it. The whole situation was sordid, dangerous and grossly inappropriate. So one lunchtime I went to Catford Citizens Advice Bureau, where I was helped to report breaches of health and safety regulations. At around the same time, I tried to set up a branch of USDAW, the shop workers’ union. There was some interest amongst the Saturday staff, but none amongst the permanent employees. One much older man patiently explained to me that it was against his interests to belong to a union because he had shares in the parent company, Debenhams. Unionisation would reduce his dividend. Like me, his wages were £16/week (my weekly income rose to £28 when I became a hospital porter) but he felt his bests interests were served by aligning himself with capitalism. It was sad and ridiculous, and it was one of many episodes in fifty years in the world of work that could have been taken from the pages of The Ragged Trousered Philanthropists.

Eric the racist manager accused me of being a habitual trouble maker, and suggested that I might be vulnerable to dismissal. I suggested that he might be vulnerable to exposure of his coffee-jar scheme. He eventually called me into his office and asked me if I would be interested in joining the company management training scheme. I laughed and told him that I was not interested, because I might end up like him. An obviously hurt expression crossed his face, and for a moment I regretted being so brutal. I realised that he could see that I despised him. It was one of the first occasions that I saw reflections of something unpleasant about myself in someone’s reaction.

My first surgical attachment as a student was with James Gillespie, a charming, likeable and relaxed Scottish aristocrat whose specialty was vascular surgery and who operated at almost superhuman speed. He was a Senior Lecturer who, as a clinical academic, did no private practice. I got on with him well, and I was eventually his house surgeon. Mr Gillespie was a redeeming aspect of that particular ordeal. During my student attachment, his senior registrar was a young doctor who has gone on to national notoriety in his twilight years. He has amused himself lately by writing embarrassingly insightless populist rants for right-wing newspapers. They concern “health tourism”, the alleged uselessness of general practitioners and similarly themes. Back in the 1970s, his biliousness had yet to manifest itself. Like most young surgeons, he was always keen to get operating experience. On a couple of occasions, I assisted him in operations where things went wrong and he became somewhat flappy. As someone who did not relish assisting at operations at the best of times, I found working with a flappy surgeon stressful. On one occasion, I had to go and find another senior registrar to sort out a serious problem mid-operation.

One morning, an elderly man in red uniform and peaked cap was seen as an emergency at the vascular out-patient clinic at Hyde Park Corner. He was a Chelsea Pensioner, a retired soldier who lived at the Royal Chelsea Hospital. This is a magnificent Wren building over-looking the Thames. The clinic was busy, and I was sent to make the initial assessment. The old man was overweight, breathless and deferential. He insisted on calling me Doctor, despite my explanations that I was not qualified. That morning, whilst eating his breakfast in the communal dining hall, he had experienced a sudden severe pain and collapsed. When I examined him, he had a large pulsating mass in his abdomen. I was as inexperienced as it was possible to be, but it was obvious that he had an abdominal aortic aneurysm and that it was rupturing. In essence, the largest artery in his body had developed a weak area that had blown out and was about to burst, just like a lorry tyre on a motorway. Once the aneurysm ruptures, the patient dies almost instantly.

I presented the case to the senior registrar, who examined the patient himself and arranged an X-ray of his abdomen. This confirmed a very large aortic aneurysm that extended very close to the renal arteries. He asked me what I thought the management plan should be. I said that the patient should be admitted and given morphine in the expectation of a peaceful death within the next 24 hours. I reasoned that the likely involvement of the renal arteries would make successful replacement of the affected part of the aorta with a synthetic graft extremely difficult, and that there was a very high chance of post-operative death. Better to make the patient comfortable and let him die. The senior registrar was dismayed by my lack of therapeutic ambition. He told the patient that we would soon sort him out, and he arranged to do the operation at lunch time.

The patient was admitted to the Intensive Care Unit after the operation. Over the next few days, he developed renal failure, then hepatic failure. He became very jaundiced and he started to bleed. He was conscious and very uncomfortable. He itched terribly because of jaundice and he was in pain. A week after the operation, he died with little dignity or comfort. The experience has stayed with me for the whole of my career. The senior registrar’s post hoc justification for doing the surgery was that it might have worked and that the old man deserved a chance. I thought that this was the wrong test. To me, the relevant question was: “What you would want for yourself or someone you love?” A small chance of some more years, with a high risk of a distressing death or a certain, but dignified and comfortable, death? My view about this has never changed. What troubled me most about the poor man’s death, jaundiced and wincing in pain, was that the most junior person present had foreseen it.

This was not typical of my experience surgical practice. There were plenty of successes, triumphs even, and plenty of humanity. I have witnessed similar incidents due to decisions that I judged ill-considered in other medical specialties, including my own. I am pleased to say that they have not been common. I should acknowledge that I have personally benefited from some very skilled surgery to various worn-out bits of my anatomy conducted by perfectly pleasant surgeons. Nonetheless, negative lessons at medical school were important to me. They taught me about who I did not want to be and about the awesome responsibility of being a doctor. There are many privileges that arise from medical practice, but there are burdens too. Knowledge of the consequences of your misjudgements is just one.

I learned a lot from trying to understand why I found surgeons so trying (to be fair, I think they found me equally trying). Of course, some of my friends, such as Dave Kaplan, became surgeons. It took a long time to making sense of my unhappiness with the specialty. Before I could, I had to acknowledge the effect that working with death and suffering had had on me, which I was not ready to do until some years later.