Category Archives: patients

The things they say to the doctor-writer

  • I put a sponge in me and I can’t get it out.
  • That was the man who cut up our cat to teach us a lesson.
  • No one wants an arsonist.
  • I wanted to kill a Hindu girl. A gun would probably be best.
  • Her baby was bribed with 40 cigarettes to go to her funeral.
  • The kid had his fingers broken for not making a spliff fast enough.
  • They kicked him in the privates and started booting him.
  • They chucked me in the canal and I could of knocked myself out and drownded.
  • My twin brother’s in prison for cars.
  • This black was spreading rumours about me so I smashed a glass over his head.
  • I’ve been getting a lot of outbursts.
  • I can’t help the people I like—pick-ups and prostitutes, my wife calls them.
  • Quality is a very good thing, but you can have too much of it.
  • I was having hallucinations of being a gangster.
  • I used to be an ex-alcoholic.
  • Life is rubbish.
  • They’re telling lies on me, they’re like vampires sucking your health from you.

Corrupt physicians, irresponsible patients

screen-shot-2017-02-21-at-08-38-12In the last three years alone, writes Dalrymple,

almost as many Americans have died as a result of opioid overdose as have been killed in all US military actions since the end of the Second World War.

The evidence suggests that the ‘epidemic’

started with, and has been maintained by, the irresponsible, incompetent, and sometimes corrupt prescribing of opioids by a portion of the American medical profession.

But this

does not altogether absolve the patients themselves of responsibility for their predicament—unless no one is ever responsible for anything.

screen-shot-2017-02-21-at-08-43-40

Dalrymple’s patients are from all walks of life

Dalrymple talks about a patient of his

who was an international dominatrix. She carried her equipment with her when she went around in a car in case she received a call for an emergency flogging somewhere in the world.

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‘The handcuffs are in your sock drawer, where they always are.’

The days when doctors were doctors and patients were patients

Screen Shot 2016-05-06 at 13.47.45Dalrymple explains that in T.S. Eliot’s The Family Reunion (1939), Warburton

is an old-fashioned family doctor whose authority has little to do with his medical efficacy, indeed is inversely proportional to it.

Warburton is able

to order a formidable dowager duchess around like a servant. His threat to decline to treat her further is enough to bring her into line.

In Dalrymple’s copy of The Family Reunion

Screen Shot 2016-05-06 at 13.51.22I happened to find an inscription offering the book as a Christmas gift to a well-known physician who was not universally loved and who was irreverently known to his juniors by the description of the stools of some of his patients with coeliac disease, namely Pale, Bulky, and Offensive.

The signatory of the note was

another physician who, in March 1938, was a co-signatory of the letter in the British Medical Journal calling attention to the plight of Jewish and other doctors after the Anschluss.

The letter ended with the words:

We beg our colleagues in all countries to watch the progress of events with the closest attention and to do all in their power, whether by public protest or by public or private assistance, to stand by any members of our profession who may suffer hardship under the new regime.

Screen Shot 2016-05-06 at 13.38.26Screen Shot 2016-05-06 at 13.39.47

Black comedy in the ward

Like something from Hancock's Half Hour, only blacker

Like something from Hancock’s Half Hour, only darker

Once as a medical student, writes Dalrymple,

I was deputed by a hospital consultant to tell a family that their loved one was dying of lung cancer.

The imparting of such information was not regarded by the consultant as very important,

indeed he thought it almost a distraction from the serious business of curative medicine.

Without any guidance as to how to do it, Dalrymple told the family

in a very straightforward way, not because of any commitment to honesty but because I could think of no other.

To Dalrymple’s horror,

one of the relatives was very hard of hearing, so I had to raise my voice to so high a volume that my voice echoed round the ward. It would have been comical if it had not been so appalling.

In any case, the dying patient might have guessed that he was in a bad way because,

when the medical notes were put out at the end of the bed before the consultant’s ward round, those that contained a diagnosis of cancer were left out. In other words, if you were lying in bed and the notes failed to appear at the end of your bed, you knew the diagnosis was bad, despite the doctor’s assurance that it was ‘just a little ulcer’ in your lung or your bowel.

May my surgeon be human-hearted

Screen Shot 2016-04-04 at 08.49.19Dalrymple points out that the media’s attitude towards medicine

swings between lauding a miracle cure and excoriating the murderous incompetence of doctors, leading to a dialectic between unfounded hopes and hostile suspicion.

Yet very occasionally it perhaps ought to be acknowledged that medicine,

for all its deficiencies and the carping of its critics, is a noble enterprise.

Doctors must act

in the absence of definitive knowledge. Sometimes this leads to tragedy, sometimes to triumph.

Screen Shot 2016-04-04 at 08.20.47A paradox

Everyone who comes under the knife

wants his surgeon to be as highly trained and as experienced as possible: but how is the surgeon to come by that training and experience unless he practises on people while he is untrained and inexperienced? Someone has to be operated on by tyros, even if they are under the supervision of more experienced surgeons. In practice, for compelling practical reasons, that supervision may be light: senior surgeons cannot be everywhere at once. What is true of surgery is true of other specialities: decisions of vital importance to individuals are taken by people who are still learning.

In the old days,

Thomas Rowlandson, 1793

Thomas Rowlandson, 1793

perhaps explanations of treatment options were less elaborate or full than they are today, but they were still given and consent to such treatments was still sought.

Patient autonomy as the single most important guiding principle of medical ethics has drawbacks.

Patients who are very ill are often in great pain, or severely weakened. Their concentration is poor, they may be irritable or in a state of panic. This is not generally the best moment to ask them for a reasoned assessment between two or more alternatives, each with its own advantages, side-effects and chances of failure. The insistence that they do so is often a form of disguised cruelty.

Dalrymple says that when he has been seriously ill or injured,

I have wanted my doctors just to get on with it as best they could, without any interference from me. So far, at any rate, my confidence in them has not been misplaced; and the paradox in the doctrine of autonomy is that the person may — in fact, often does — wish to abrogate it.

Surgeons

need human as well as technical understanding, and kindness is at least as important as respect for patient autonomy.

Men of action

Screen Shot 2016-03-08 at 22.08.41Doctors, writes Dalrymple,

are inclined to believe that doing something (especially when it is them doing it) is better than doing nothing. They mistake benevolent intentions for good results, believing that the first guarantee the second.

Besides, doing something

stimulates the economy.

Dalrymple comes across a paper by Danish researchers that

assesses the extent to which published reports of trials of screening procedures, such as mammography, colonoscopy, PSA testing, etc., note their harmful effects and consequences as well as their positive ones.

This is important ethically because

screening reverses the usual relationship between patient and healthcare system. In screening it is the healthcare system that initiates the contact, not the other way round. Screening is offered to healthy people, or at least to those complaining of nothing; moreover, the chances of benefit from screening are often slight, and those who benefit do so in a sense at the expense of those who are harmed.

Politely Told to Fuck Off

Station at the London suburban settlement of Barking

Station at the east London suburban settlement of Barking

That is what PTFO stood for in the old handwritten doctors’ notes which, says Dalrymple,

in lapidary fashion told you a great deal about the patient (or sometimes the doctor).

N4N meant Normal for Norfolk,

which is not a reference to the charms of the countryside of that county.

Here again! or Not again!

told you either that the doctor failed to diagnose a troublesome or occult chronic condition, or (more likely) that the patient was a frequent attender whose visit to the doctor might have been the highlight of his or her week, and who cherished symptoms like a hobby.

LNWL stood for Life Not Worth Living.

The travails of a patient were reduced to, or summarised by, these four letters.

TATT meant Tired All The Time, meaning the patient was suffering from

a form of taedium vitae.

IG11 stood for

the madness of a patient, not in the medical or literal sense but the metaphorical one, IG11 being the postcode for Barking.

Revenge of the nightclub-queue slaves

Screen Shot 2015-06-11 at 07.49.29Observe, writes Dalrymple, a queue of people waiting to get into a nightclub,

how meekly they allow themselves to be searched by the thuggish-looking bouncer-greeters (who incidentally have a very high rate of violence towards women). How the bouncer-greeters lord it over them! What power, moral and physical, they wield!

The bouncers have a star-like quality:

I have seen a greeter-bouncer drive by (in a pastel-shaded BMW), and have heard the admiring comments of those he and his type have humiliated a hundred times.

The people in the queue,

supposedly so rebellious and anti-authority, are willing to endure almost any humiliation so long as they gain entry into one of the circles of hell, where the noise is so great that they enter a trance-like state almost at once. Slaves could hardly be more abject.

It is an illusion that everyone wants to be free,

but everyone wants to assert himself, and no one likes to be humiliated.

How do the abject slaves of the nightclub queues revenge themselves for their humiliation at the hands of the greeter-bouncers?

By being insolent towards those in authority who nevertheless have an infinite duty of care towards them, such as doctors, who cannot answer back. A young man who grovels to a greeter-bouncer in a night club queue will have no hesitation in cheeking a doctor and letting him know who is boss.

The doctor

cannot refuse to cure a patient merely because the patient shows him scant respect, and for the first time the patient knows it. Thus we see the dialectic of dependence and resentment in a population that is no longer expected to regulate itself, but expects always to be protected from the consequences of its own tastes and conduct.