Graduation Day

The last year at medical school was marked by a gathering sense of dread as Finals approached. Although we had had innumerable tests over the years, these were just way marks. Qualification rested entirely on the results of a heavy schedule of written and viva voce exams taken in late May and early June, and so did the award of honours and prizes. Having skipped a lot of the lectures for five years, I had a certain sense of vulnerability about Finals. Furthermore, I had form. I had actually failed two subjects during the course, first-year anatomy, and child psychiatry in year 4.

I have never got on with child psychiatry. It is not that I do not like children. My wife and I have several, and I speak to them regularly. My difficulty with child psychiatry was its culture, or at least, the culture of the teams I encountered early in my career. The specialty has a very different history to the rest of psychiatry. It grew out of the child guidance movement, which was more closely aligned to social work than to psychiatry. It was psychoanalytically orientated from the outset. When child guidance was replaced by new departments of child psychiatry, they linked to paediatrics, not to mental health services. Consequently, we were taught child psychiatry as part of the paediatric curriculum.

In theory, child psychiatry’s strong emphasis on psychotherapy was in line with my own interests. Furthermore, as an academic discipline it was led by a truly outstanding scientist, Michael Rutter. Rutter conducted impressively rigorous research. His work brought social and biological factors together in a way that is rare in psychiatric research. In contrast, my experience of child psychiatry, both as a student and later as a psychiatric trainee, was that there was an unacknowledged but pervasive undercurrent of therapeutic nihilism with respect to a substantial proportion of the children who were referred. For example, many referrals were of boys with conduct disorder.  Assessments often ended with the conclusion that there was little that could be done to rescue the child from a life of delinquency. Having once been the second-naughtiest boy at Kidbrooke Park Junior Mixed School, this bothered me. In my case, a teacher, Lynne Edwards, made an enormous difference to my happiness and academic performance. Although they were often struggling with much more difficult circumstances than mine, I found it hard to accept that there was a fundamental difference between wayward working class boys from Tooting, many of whom were Black, and kids like me. It seemed totally inadequate to accept that there was nothing that could be done to help them.

Picture of the front cover of the book The Myth of Mental Illness

I strongly suspect that the main reason why I failed the child psychiatry examination was because I mentioned Thomas Szasz in my viva. I cannot now imagine what made me do this. I had read Szasz and I had noted with disapproval that he was a right-wing libertarian. I was the only person in our year who failed child psychiatry. My ignominy was complete when I found out that no one at all failed it the following year.

I was friendly with Simon Gowers at medical school. Like me, he expressed a firm intention to become a psychiatrist. He went on to have a career as an eminent child psychiatrist. He has an international reputation as an eating disorder researcher, and he has made major contributions to national policy. Simon was another socially dislocated student. He had grown up in Hounslow and, for reasons that were unclear, he possessed a comprehensive collection of Leicester City FC matchday programmes. I told him that it was unlikely that they would ever be stolen. Like me, he had a girlfriend from outside of the closed world of medical school. They married about three months after us, and, like us, they are still together. We shared our formative years as trainee psychiatrists at St George’s in an amiable relationship, but I am sorry to report that his personable exterior conceals a deadly competitiveness within. Or at least, that is my explanation for his persistent habit of beating me at everything. On reflection, perhaps I am the one afflicted by deadly competitiveness. Maybe Simon’s problem is just his tactless habit of winning. Colleagues who have worked with both of us even say that he is nicer than me.

 As students, Simon and I usually met in the medical school club games room. He consistently beat me at pinball. He could elegantly nudge the table to keep the ball in play without activating the tilt mechanism, whereas if I so much as coughed, the lights went off, the flippers went dead and the ball trickled miserably down the hole. He also had complete mastery of the recently installed Space Invaders machine. By modern standards, Space Invaders was a dull and repetitive video game, but it demanded a degree of hand-eye coordination and a speed of reaction that I lacked. I would have cheated at Space Invaders if I could have. I certainly cheated at chess. This did not stop Hamish Wallace from beating me, but there was a compensatory satisfaction in his failure to notice when I put pieces back on the board after they had been taken.

Simon went on to prevail in two crucial job interviews early in our careers, and then, just to rub it in, he was appointed Professor of Adolescent Psychiatry at the University of Liverpool. At that time, I had been an honorary clinical lecturer in the department for some years. Simon has now properly retired and moved back down south. In retirement, he has demonstrated an admirable appreciation of the importance of work-life balance and an ability to know when enough is enough. I lack these qualities, and I continue to work flat out. Fortunately, I do not bear a grudge.

In the end, I passed Finals without any great difficulty, but I was worried right up until I saw the P by my name on the results sheet. In contrast to my cavalier attitude to lectures, I had always turned up for all of the clinical teaching that was available. We had a period for elective study in the final year. Many people went abroad to experience medicine in a low-and-middle-income-country setting. Tricia went to Burkina Faso, which was then called Upper Volta. It was officially the world’s poorest country and it sounded really grim. Simon went to India. A lot of the people who went to exotic tropical destinations came back with exotic tropical diseases, some of which necessitated months of visits to the London School of Tropical Medicine. I elected to experience medicine in the quotidian setting of the two St George’s libraries, one in Tooting and the other at Hyde Park Corner. I needed to secure my basic knowledge in time for Finals, so I systematically worked my way through the curriculum from textbooks. The newly-opened library in Tooting was an excellent modern facility with a device that you had to pass through to prevent you from stealing books. The device had a notice warning that it could stop cardiac pacemakers from working, which seemed a little harsh.  The library was on two levels, and downstairs there were small windowless private study rooms. They were soundproof, air conditioned and, crucially, they had no smoke detectors. This meant I could smoke and read undisturbed. I may have avoided amoebic dysentery by taking my elective within SW postcodes, but in the process I laid the foundations of chronic obstructive airways disease.

In the spring of 1980, the library at Hyde Park Corner was rarely used by anyone but me. It was packed with interesting old books but there was no security whatsoever. The contents of the hospital at Hyde Park Corner were slowly being moved to Tooting in anticipation of the site closure. The library had been the dissection room in the 19th century. It had still had galleries on four sides that had allowed students to view cadavers. It was the room where Henry Vandyke Carter made his meticulous illustrations for the first edition of Gray’s Anatomy. The dark wood and cast iron fittings gave the space an appropriate gravitas. As I was rarely disturbed, I could smoke in there as well. Continuous use of nicotine allowed me to study efficiently for many hours without a break, but the stimulant lingered in my blood stream and made it difficult to sleep when I eventually got home.

Front cover of the book Gray's Anatomy

One evening whilst I was studying at Hyde Park Corner, I was startled by the sound of a loud explosion nearby, followed by gunfire and then a lot of sirens. This turned out to be the SAS storming the Iranian Embassy in Prince’s Gate in order to end the siege there. There were several sieges in that part of London in the 1970s. The Spaghetti House siege in Knightsbridge in 1975 involved Stockholm syndrome, where the hostages and captors became so close that a hostage went on to visit one of his captors in prison. Late in 1975, the IRA active service unit that had attempted to assassinate Alf Knott were spotted by the police as they fired shots into a restuarant in Mayfair. There was a car chase, following which they took a middle-aged couple hostage in their own flat in Marylebone.

Generally speaking, I did not study at home if I could avoid it. Our flat was for loud music and our non-medical social life, not for study. On Saturday mornings, Steve and Eileen would come downstairs from their flat and we would all sit in our large sitting room and watch the gloriously anarchic childrens’ TV programme Tiswas. On Saturday nights, we would go to gigs, followed by sub-titled foreign language art-house movies that were broadcast after closing time on BBC2. We had all noticed that every few weeks the house would shake at four in the morning as a mysterious unscheduled train went past. On one occasion, I managed to get to the window in time to see that the train consisted of a lot of flatbed wagons, each carrying long tubular objects under tarpaulins. We were troubled when it was revealed in the newspapers that these were ballistic missiles on their way to nuclear submarines at the Medway ports. Thus primed, I was awoken one morning by a ferocious shaking of the bed and a terrifying certainty that a nuclear weapon had detonated in the immediate vicinity of our flat. The girl’s school over the road had closed some time before, and no one had bothered to warn us that they were going to demolish it. An apocalyptic interpretation of crashing masonry was reasonable, given our close proximity to passing warheads.

Not long after this, we received a letter from the site construction company saying that they wanted to operate a crane over a metre of the property we rented. They were obliged to get a licence from each tenant, and offered us £25 in return. I wrote back, politely declining to grant the licence. That Saturday morning, two men in suits and hard hats called at our door. We invited them in and gave them coffee. They looked uncomfortable amid the jumble of duvets, toast, mugs and LPs. In the background, with the volume turned down, children were rioting on Tiswas. The suits explained to us that operating the crane over our flats was essential to the project, and that delay in granting the licences would cause substantial expense. I suggested that they move the new building a metre closer to Bromley High Street. They became remarkable bad tempered with us, but we managed to negotiated an improved fee of £100 per flat.

Despite the strength of my orientation towards psychiatry, I had a brief flirtation with radiology during my final year. By 1980, the implications of the advent of CT scanning were becoming evident. The ability to get cross-sectional X-ray images of the human body was a massive step forward in making diagnoses without invasive investigations. It was clear that further scanning techniques would soon follow, and it was expected that it would be possible to capture real-time images of physiological activity. The medical press compared the likely transformation in diagnostics to the transformation in therapeutics after antibiotics were discovered. I had been a physics nerd at school, and the combination of medicine and physics was attractive to me. There was radiologist at St George’s called Anton Joseph who was an ultrasound enthusiast, and I found his work really interesting. Ultrasound had been available for more than 10 years, but the machines had improved and it seemed that post-CT programming expertise might transform the diagnostic power of ultrasound too. Nevertheless, I was still reading about psychiatry for pleasure, and radiology just could not hold my interest. The flirtation passed, as flirtations will.

Finals were intense but not necessarily intellectually stretching, more of a test of memory and endurance than anything else. Towards the end, I developed exam-fatigue and found it difficult to tell the difference between firmly-held knowledge and improvisation. I clearly recall being asked about an X-Ray in my surgery viva whilst I stared out of the window at the wet rooftops of Tooting terraces, unable to decide whether “right-sided massive pleural effusion” was a proper medical term or something I had just made up. My last test in Finals was a viva covering community medicine and psychiatry. Having read a lot of psychiatry over the previous 18 months, I did not really bother to revise the subject, which turned out to be a mistake. On the other hand, I had worked quite hard learning about community medicine (essentially a synonym for public health), which interested me. Public mental health has been one of my main preoccupations in the second half of my career.

The viva kicked off with psychiatry questions, which progressively became more difficult. I could answer them, but I felt that some of them were a bit beyond the undergraduate curriculum. I was eventually asked a question that I could not answer, which concerned an article that had been published in the British Medical Journal recently about some aspect of post-natal depression. I had not read it. Then the viva was over, without being asked any questions about community medicine at all. As I left, I realised that I had had a viva for the psychiatry prize.

The prize was won by Gulshan Bhatia. Unlike me, Gulshan had read the post-natal article and she won the prize fair and square. She was incredibly bright and she won several prizes. Gulshan had a real edge and she did not suffer fools, which I admired. She had had an international childhood, and she spoke with an American accent. Her parents lived in the Barbican and attended the mosque in Regent’s Park. As we came towards the end of our pre-registration house jobs, we started applying for Senior House Officer jobs. A pattern developed whereby Gulshan was not shortlisted for jobs. Given her obvious ability and her academic track record, the only conceivable reasons were the combined effect of racism and sexism. Professor Tom Pilkington suggested to her that she try applying for jobs under a different name. Gulshan became exasperated and decided to give up on a career in the UK. She migrated to the USA, where she works as a physician in internal medicine in San Jose. It still makes me angry to think about it.

After Finals were over, there was nothing to do for a fortnight. The results were due to be posted on a board in the atrium of the medical school in Tooting on the morning of Thursday 19th June 1980. We were obliged to attend in person and we were forbidden to phone for our results. My wife, Richard (who had been my partner in many undergraduate placements) and I went to visit my sister. She was finishing her first and only year studying Chemistry at the University of East Anglia in Norwich.

Dexy’s Midnight Runners were playing on campus on Wednesday 18th June and my sister was supposed to get us tickets. She was slow off the mark and they sold out. She only admitted this after we had arrived. Dexy’s were hot at the time. They had released two excellent singles and they had a reputation as a killer live act, but as yet they had no album on the market. In their early days, their music was a kind of fusion between punk and sixties soul, much as the Specials’ music was a fusion of punk and ska.

The sound of brass-driven soul music was pioneered by Atlantic Records in New York and the Stax record label in Memphis in the 60s, and it was enjoying a major revival. This was led by Southside Side Johnny and The Asbury Dukes in the USA and by Graham Parker and the Rumour in the UK. Elvis Costello, who was a weather vane for what was fashionable, had released a soul-inspired album, “Get Happy!” The movie The Blues Brothers went on general release that summer. Ticketless, we sat in a plaza outside of the hall listening to Dexy’s perform their set. The music was great but Kevin Rowlands was utterly obnoxious. He was the auteur of the band, and he had a pretentious way with lyrics; for example, one song listed great Irish writers. His stage presence was an artless pastiche of John Lydon’s stance in the Sex Pistols  “I hope you’re enjoying this, you snivelling students, languishing in your state-subsidised public toilet”. I was pleased that we had not paid good money to be abused.

Photograph of a large pub on a corner in the Strand

The next morning, we took an early train back to London. At Richard’s instigation we travelled first class, because the cost included a good quality full English breakfast and he had calculated that it worked out cheaper overall. It was the only meal I ate that day. On arrival at Liverpool Street station, my wife went off to work a late shift at King’s College Hospital. Richard and I walked to the Strand, where we went for a pint in The Wellington, a grand Edwardian pub that we had occasionally visited when we were studing at King’s College London. I went to buy the beers, and when I returned, Richard greeted me by saying “Hello, Dr Poole”. He had defied the rules and called the medical school from the pub’s pay phone. He had somehow persuaded a porter to check if we had passed. We both had. There was a moment of massive relief, followed by euphoria, then doubt that this might be a practical joke, then euphoria again, then doubt that the porter might have read the result wrong . We took a tube train south on the Northern Line and arrived at the medical school mid-afternoon. Then I partied for 12 hours.

I only have fragmentary memories of the Graduation Day party. This is not due to the passage of the years. The next morning I had the worst hangover of my life and my recollection of the night before was patchy. I remember much hugging and hand-shaking, and a lot of dancing once the disco started. Although euphoria continued to wash over me intermittently, some of my feelings were decidedly mixed. A couple of people had failed, and, not surprisingly, they did not turn up for the party. I felt badly for them. There was a sadness that graduation meant endings. We had travelled together through medical school for five years, 21% of my life so far, bonded by place and circumstance, and little else. It was obvious that after that night, we would never be together as a group again.

Similarly, many friendships would not survive separation and diverging career trajectories. I had a sense of lost opportunities and of having failed to put sufficient effort into relationships with other students, because I always had a strong focus on my non-medical world back in Bromley. I wrote two songs about that night. The first, Graduation Day, was written just over a year later. The second, an instrumental called Not A Word Was Spoken,  was written and recorded much more recently. It refers to a tiny moment in the course of a long evening. I was dancing with one of the women when something happened and we made protracted eye contact. Then we kissed. Then we danced some more. As the song title suggests, neither of us said anything nor made any reference to it thereafter. It was of no real importance, but the memory evokes a sense of unspoken possibility that would never be realised.

I look a mini-cab home at about two-thirty in the morning. Instead of quietly letting myself in, I rang the door-bell, waking my wife. As she opened the door, I expansively proclaimed “I’m a doctor!!” “Quite likely,” she replied “but you are also drunk” and went straight back to bed.

Two days later, as I rounded the corner into Bromley High Street, I saw that an elderly man had been hit by a car whilst crossing the road by the railway station. There was a knot of people around him and a woman in her thirties was kneeling by his side. There was a lot of blood from a major head wound and he was deeply unconscious. I asked the woman if she needed help. She said she was a ward sister from the hospital up the road, and she had sent someone to call an ambulance. She was concentrating on keeping his airway open and avoiding unnecessary movement of his head, in case his neck was broken. I took his pulse every few minutes, checking for a slowing that would indicate rising intracranial pressure, but I was mostly occupied telling people that it was unhelpful to put coats on top of him and that we had the situation under control. Out of nowhere, two uniformed St John’s ambulance volunteers appeared and tried to hustle us out of their way so that they could take over. “It’s ok,” said the nurse “I’m a nurse” “And I’m a doctor” I added. I was self-conciously aware that it was the first time that I had ever uttered those words to a stranger. The St John’s ambulance people backed off, but the nurse gave me a hard stare. “Well, you certainly don’t look like a doctor” she said.