It’s windy here…. you’d like it.

Happy Birthday Kitey!

Love is… Maths?

I had long believed that pain, like beauty, was in the eye of the beholder. It was my belief that empathy, the professional edition of sympathy, was fashioned to address this quandary.

The concept of empathy is premised on suffering and ill-health remaining confined within an individual, incapable of being accurately transmitted from the confines of the bed to the clinician practicing at the bedside. The naive medical student is taught how the empathetic clinician will effortlessly build rapport while naturally eliciting patient concerns. One may consider empathy a clinical skill - designed to placate the patient, to assure them that they are the most important person in the room. I began to ponder the value of empathy and the very notion of pain following a recent experience in a small private room in a city hospital.

As with all clinical rotations, we had been attached to a team for the day, to an intern to be more precise. I have begun to consider an intern’s position as the cloudy period which occupies the formless transition between student and doctor. Still learning but certainly not learned. Respectable but not quite respected. I digress. It was a Friday in this oddly ecclesiastical private hospital, a day not known for its clinical activity and often chiefly associated with complementary stationary and tepid eastern food in exchange for attendance at a monotonous pharmaceutical seminar. My fellow students and I had completed our course of work for the morning and, after consuming some heavily spiced chicken and gaining some heavily branded writing implements, we bleeped our newly qualified mentor for further instruction. Our page was quickly returned and we were instructed to make for a room on the second floor where we were to observe a minor procedure being performed on a surgical patient.

We adjusted our attire and hastened to the wards, rounding the heavy wooden staircase while brainstorming pertinent questions that may be asked of us during the procedure. We arrived at the ward where the rounded hand of the seated staff nurse emerged from behind a high countertop to motion us into the particular room. We knocked on the door and the high pitched voice behind the thick mahogany directed us to ‘come on in’.

Three of us entered the room and were greeted by our intern gowned and gloved. Before him lay a heavy set and equally heavily sedated man who did not acknowledge our arrival. A sense of pain filled the room. “Can you numb it some more?” muttered the patient, “please make sure you numb it again”… The procedure, while deemed minor, was incredibly invasive. It involved the introduction of a larger catheter into the patient to replace a smaller predecessor which had been removed before our arrival. The commentary began and we were talked through the preparation for the procedure. I was asked to assist in the procedure, mainly as an extra pair of hands. There was a palpable sense of tension in the room, as thepreparation drew to a close. The intern took position bedside and began to introduce the catheter. Everything changed. Screams filled the air, the patient bellowed loudly. So loudly that the timid words of the twenty-something intern were lost. The catheter was advanced, the shrieking continued, the patient began to writhe with the intense pain. The steel bed throbbed loudly against the wooden wall panelling adding more to the din. Tears ran down the gentleman’s blood red face, his eyes glued shut as he sat forward as if he were midway through a sit-up. I had never seen such pain.

The presence of an anatomical obstacle sounded the crux of the procedure. The intern warned the patient of the imminent increase in pain, his words again lost under the sobbing of the rotund middle aged man. At this point my female colleague left the room for reasons best known only to her. My male classmate, who had fallen into a trans-like state, remained in the room. As the heavy door slammed behind my shaken colleague the intern advanced passed the prostate causing the noise to reach a crescendo. A deep purple hue suddenly infused the unfortunate man’s face while the intern obliviously continued his commentary. Then - nothing. The room fell silent. The patient drifted backward, his head hitting the pillow and the effect of the sedatives once again becoming evident.

“….and record that in the chart” continued the intern. His now audible words snapped my attention, I quickly realised I had completely lost track of the methodology underpinning the procedure. I had forgotten I was present to learn and not to merely to experience. Eventually I would be the gowned and oblivious. Pain, communicated from the beholder, had penetrated my concentration rendering me fixed in a stare desperately trying to exhibit empathy – and failing miserably.

I feel it would be remiss of me not to say that I feel the preceding text does not go far enough to portray the intense visceral pain I felt for those few minutes, how elongated time became, how space shrunk. Hyperbole notwithstanding I feel I betrayed my role and my responsibility to the patient. This gentleman had consented to our presence for the purposes of education. A right to invade his privacy has been afforded to us, a right that was accompanied by the responsibility to learn. I had reneged on this obligation and had instead become preoccupied with the notion of empathy. In the several weeks which have passed since this event I have resolved that, while desirable, it is not our primary duty as students to display empathy. Not yet. We must achieve competency, make steadfast our concentration and maximise each experience in order to best respect the sacrifice of our patients. I continue to wonder how much scope remains for empathy when one becomes so very consumed with proficiency?

“It’s a curse Doc! It’s been there with a few weeks, tis surely gettin bigger. Feckin yoke!”

My ears can hear the words lilting from his eighty year old mouth, my eyes recognise his leathery lips as moving but my mind is certainly not listening. I have so much to do. Too much!

A general surgery clinic is as close to witchcraft as modern medicine gets. Your typical patient will present with a nebulous complaint which has usually outsmarted numerous medical teams. Eventually the “real doctors” concede and refer to the “cutters”. This white flag usually takes the form of a generic and hurriedly dictated letter from a junior doctor –

__

Dear Mr. S. Urgeon,

Thank you for seeing this patient who has had abdominal pain of unknown origin for three years.

We would appreciate your opinion.

Sincerely,

Dr. N. Chd

Intern To. Dr. Medicus

__

It’s 9:28am. I have endured four rituals this morning. Our four patients have arrived with matching riders, each almost identical in brevity and obscurity to the above archetype. Each gentleman received a ceremonial tummy rub, an unpleasant digital invasion and departed with a technicolor fan of referral cards orchestrating a barrage of further procedures. The third patient, an eighty year old gentleman has entered and I’ve noticed my mind has become completely disinterested. I do not care for his name or where his particular pain resides. I sit quietly as the surgeon begins the customary examination and recites the almost liturgical stream of direct questions. Anger is building in that space between my ears. I know a career in surgery is not for me! The powers that be have assigned a mountain for this week. I am nowhere near the summit. I’m certain my time could be better spent elsewhere.

The surgeon permits the man to redo his trousers, turns to me and asks what I think the plan should be in this case. He’s surprised when I give him exactly the answer he’s looking for. I’m tempted to scream at him – “IT’S THE SAME EVERY TIME!!”.

Medical education often mirrors a gold rush. Many people are attracted by the ruckus. Their enthusiasm is quickly quelled by the hum-drum of panning until every so often a nugget of knowledge excites the patch of cortex which initially coveted that which glistened.

Today I longed for a golden nugget. I am forced to settle for imbibing the amber viscera of a Cadburys Crunchie while supping from a cup of school-bus-yellow tea.

Thank God It’s Friday.

We are continuously reminded how history taking is the cornerstone of diagnosis. How, with good rapport and a conversational tone, one can master the art of history taking. Not too long ago, while attached to a senior physician at a teaching hospital in the city I saw this art, this poetry in motion. After informing me of the fundamentals of the case outside the private room, my mentor for the day knocked the heavy door lightly and on entering immediately locked eyes with the bed-bound gentleman. He took slow steps toward the bed casting his eyes the length of the slight body before him – assessing all the while. On approaching the bed a freshly sterilised hand was outstretched and the discourse began as if the doctor were a concerned friend visiting an old school chum. The discussion did not appear one sided although the skill being employed was obvious to my trained ear. The practitioner guided the conversation as if he were leading a dance, a lead in which his partner, a morbid octogenarian, followed obliviously until the tune ended some five minutes later. Little was said after we left the room as I believe my tutor was satisfied I had learned from the experience. I had.

Several months have passed since that experience and it remains a stand-out clinical performance. Today, at an out-patients clinic in a small hospital in the midlands, I was afforded the opportunity to test my ability, to gauge how my art was developing. The patient was presenting for investigation of a thwarting personal problem and had sparse notes to explain his past. I took a moment to thumb through the thin file. There was very little out of the ordinary. The presenting complaint, medical and family history were succinctly stated in true medical fashion. I turned the page to reveal the gentleman’s brief social history which read – “62yr male, lives alone, unemployed, divorced.” I was struck by the image this string of words had projected, how lonesome and disappointing it seemed.

Gathering myself, I called the gentleman from the waiting room and he quickly followed to join me in the consultation room. I was instantly surprised, here was a man who appeared completely at ease, jolly – almost festive;

“To be honest with ya doc I was gonna call and cancel but I thought it too short notice so I thought I’d be polite and come along”.

As we began talking it became clear that his complaint, perfuse sweating on exertion, was not life threating but certainly compromising. Weary of prying I moved to flesh out the impact of the condition, I learned that it was first noticed two months ago while dancing the quick-step at the local community hall. I was taken aback by the notion of this fellow, whom I had pinned as lonely and depressive, dancing the quick-step. By the time the consultation ended I realised that here was a gent never more at peace. 62 years of cherished memories, a warm peaceful home, unemployed but busy with odd jobs provided by local farmers, divorced yet the proud father of three, healthy, happy and progressive children.

Having encountered today’s quick-stepping divorcee, I feel I could now offer some words of advice to the physician who originally so impressed me. In history taking it can be easy to cajole the patient, check boxes in your head and fill in blanks. It is considerably more trying to identify the person behind society’s labels, to permit the bedbound to pick the tune and lead for a few steps.

Come to think of it, I am not quite sure what “24yr male, living alone, university student, unmarried” says about me.