Reunions

Even then, I had a great future behind me

Even then, I had a great future behind me

From time to time I’m invited to speak at medical school reunions of those I taught decades ago. It’s generally the successful ones who attend: in their 40s, on astronomical salaries, often with kids at schools where fees are more than my stipend. One or two have jetted from Hong Kong or Sydney just for the event.

I begin my speech by sympathizing with them. Despite the trappings of success such as big houses, tennis courts, swimming pools, and posh cars, this is a difficult time of life. Children are getting more and more expensive and fractious, relationships are creaking with divorces past or looming, and parents are beginning to lose their marbles. I remember it well, though I never had the telephone number salary.

Standing in front of them is this ‘owd feller’ that they invited to speak because they remember what he used to be like. Even in those days, though, he had a great future behind him, for he peaked when he was 10. They are shocked to see the fat old cynic he’s turned into. They’re astonished at what he’s become. They’re not alone. Some praise his courage for this, slightly envious. Some are mildly amused. Some are dismissively sceptical. But in general they’re lovely, warm, courteous and good fun. Many of them talk privately about an interest in ‘spiritual matters’ that is touching, and displays a vague longing – a certain trace of silent sadness. ‘I can’t swallow all the dogma,’ they say, ‘but I do love churches and church music.’ Me too. I don’t think the man in sandals was known for his love of dogma.

You see, dear reader, many of these worthy people are beginning to be bored. You need to understand that though medical training is lengthy and requires a good memory, it is absolutely not intellectually or conceptually challenging. Consider too that the human body recovers from disease often despite doctors, not because of them: once carpenters and plumbers have done their work, masterly inactivity is often the best ‘treatment’. What doctors need is common sense and humanity, and in my experience those qualities don’t necessarily go hand in hand with academic brilliance. When you’ve removed 321 gall bladders, or done 534 hysterectomies, or seen the effects of deprivation and poverty that you can do nothing about, work begins to pall. And there’s still 15 years to go. Boredom.

How will they cope? Many take to golf. I’m not old enough to play golf. Some will develop a fondness for the bottle or some other peccadillo. Some will spend more and more time on their yachts. When I was an intern in London, every Sunday I had to ring Burnham-on-Sea, where the consultant had his boat, to tell him of his operation list next day and let him know how his private patients were faring without him. Some will become bigwigs in professional bodies, sitting in panelled rooms on committees that reorganize things that don’t need reorganizing. Some try to recapture lost youth propping up the bar at what used to be Lansdowne Road and contrive friendships with players. And so on. A certain trace of silent sadness. 

Speaking at a reunion is a bit like going into a fusty room that might have been better left unvisited. It’s hard to resist, though. I return saying ‘I won’t do that again’. But I do. The invitation comes, and I feel vaguely honoured. I’m a fool, of course. I rather suspect that the ex-students think I’ll be as subversive now as I was then. In fact, I’m much, much more.

The road to glory?

road-less-traveledA twinge of guilt still hangs over one Christmas in the early 1960s. It had been decided that I was going to be a doctor, so one of the presents was a plastic model of a person you could take to bits and put together again, thus learning about the structure of the body. And I never even opened it. I knew it had been expensive, hence the guilt. Before long, in the gloriously impressionable early teenage years, my heart was seduced by music and architecture. Glamour of a sort. The great awakening. The plastic human was shoved to the back of the cupboard.

The hope of Cambridge (never Oxford) enabled me to imagine that I could work in one world but live in another. This is the story of Magnus Pym, A Perfect Spy, but then we’re all spies one way or another. When I was 11, I chose Latin for Cambridge entrance, only to find after a year that Cambridge dropped the Latin requirement. I went through secondary school in a fug really. Music after school was the consolation for what went on in it. I still can’t see why I had to learn about Bessemer converters. I liked O-level biology though. Zoological classification was interesting, seeing patterns in the animal kingdom. A-level was a different kettle of fish, ho ho. The school was one of those chosen to try out the new Nuffield A-level syllabus. Why did we have to see for ourselves? Why did we have to reinvent the wheel? Why did we have demonstrate the bleeding obvious? Why not just tell me? I’ll believe you. Then we can get on with interesting speculative stuff and think about ‘so what?’ Nuffield biology had as high an opinion of me as I did of it, for my A level Biology result was an E – a scraped pass.

686px-Haeckel_drawingsFirst memories of Cambridge days were not dead bodies in the dissection room, but the lectures from the Professor of Anatomy, Richard Harrison, in which he told us about primates (apes not archbishops), the group to which we humans belong. I was entranced by tarsiers, lemurs and so on, and how we were like them. I enjoyed embryology, hearing that our nine months of intrauterine development could, at a pinch, be seen as something like a kind-of speeded-up evolution—ontogeny recapitulates phylogeny. Fascinating stuff that has stayed with me and continues to intrigue: the evolution of reproduction.

Max, ten years before I knew him

Max, ten years before I knew him

The Senior Tutor of the Cambridge College I was at was himself an anatomist, Dr Max Bull. This was in the late 60s and early 70s. Men only, gates closed at 11 pm, permission needed to be away from College for even one night, dons regarded by statute in loco parentis. Max had a tough time as Senior Tutor in those days with student unrest, revolutionaries, riots and the like. They say if you can remember the 1960s you weren’t there. I wasn’t there. I suppose I became an anatomist because of Max: ‘if that’s what an anatomist is, and if that’s what an anatomist does, then I’ll be an anatomist’. In about 1974 Susan and I went to see him to ask his advice. He counselled against a career in anatomy. ‘You’ll never earn much.’ He was right. ‘You’ll always be looked down on by other medics.’ He was right. ‘It’s publish or perish out there; you’ll never get anywhere if you are like me, only interested in teaching.’ He was almost right: as one of my former colleagues in Dublin said to me, ‘the only reason you came to Dublin was because you’d never have made professor in England.’ Like all good advice, Max’s was not taken. He taught generations of Cambridge students, and was, with Dr Gordon Wright, a truly memorable teacher. Another anatomist memorable for other reasons was Dr Michael Message. His contributions to the anatomy course were lectures on statistics. No, I don’t see the connexion either. Here’s a story about him and me.

Picture the scene. First year anatomy viva voce exams, summer 1970. It’s customary for students to dress up for oral examinations: suit, tie, polished shoes etc. But nobody told me that, so here’s this still rather naïve state school boy from rural Cumberland in polo neck and grubby jumper waiting with the suited sophisticates who knew the form. We hope we will be sent to anyone but Dr Message. ‘Mr Monkhouse to Dr Message’. In I go. He passes me a fetal skull and asks me a few questions about how the skull forms and grows. Then he hands me wet specimen dripping with preservative, a triangular shaped wedge of meat on top of a chestnut, with a number of tubes attached.

‘Tell me, Monkhouse, what do you make of this?’
Silence.
‘Come on, come on, haven’t got all day.’
‘Well, Dr Message I don’t know, but it looks a bit like a heart, though if it is it’s not human.’
Dr Message rolls his eyes heavenwards.
‘Oh, come on, come on. Surely you can do better than that.’
More silence.
‘Well, Monkhouse, if I tell you these tubes here (pointing to two of them) develop from the mesonephric ducts, what can you say then?’
‘Well Dr Message’ says I with a broad smile (Oh God, no, not a smile, anything but a smile), ‘I can tell you it’s not a heart.’ Then I chuckled.

That was the end of that. The thing was a bladder (the triangular wedge) and prostate (the chestnut) and the tubes derived from the mesonephric ducts were the ducts that carry sperm from testes to penis through the prostate. The other two tubes were the ureters carrying urine from kidney to bladder. I was right of course: it wasn’t a heart.

Talk of prostate reminds me that I must take a break.

Depression and exaltation

creativity-disease-how-illness-affects-literature-art-music-sandblom-philip-paperback-cover-artA letter in the Church of Ireland Gazette a few weeks ago asked why the church officially ‘has nothing to say in relation to the one in four people who attend our parishes every Sunday … [who] at least one time in their life experience serious problems with their mental well-being?’ The writer points out that there are plenty of resources on interfaith dialogue, building maintenance, liturgy, etc, but ‘no resources to help people who are struggling with mental health issues.’ I meet many people who tell me they are clinically depressed but do not wish it to be widely known: society and the church have a peculiar pre-scientific attitude to mental illness. Some of them cope without drugs, some are on antidepressants all the time, others on and off.

Let me ask: what resources would you like to see made available?

I need chemicals. I don’t blame myself for this. I don’t say, ‘if only I had, or hadn’t, done this, or that …’ I accept that something about the production and/or metabolism of my brain chemicals means that I cope better with help. This is not new: it’s been going on for over 20 years, and when I look back I see signs in my youth. Furthermore, I think previous generations showed signs too, not that I recognized it at the time. I’ve been on sertraline for years. When we went to France last summer I forgot to take them. ‘Never mind, I’ll see what happens’. What happened was that I began to feel ‘hunted’, agitation bubbling up. I started the pills again. Once since then, I’ve stopped them with much the same the results. Without the pills, I feel that the cosmos is not on my side. Paranoia is too strong a word, but certainly heightened watchfulness. From an evolutionary point of view, this is no bad thing: when we were hunter-gatherers we needed to avoid being eaten by predators, so watchfulness is hard-wired in. Another thing I notice without pills is a heightened tendency to shock (strong enough, some would say, without being heightened). This can be very amusing, at least to me—naughty child stuff. It’s as if I observe a torrent of words coming from another creature within me. I can understand why people thought, and think, in terms of possession and demons.

The GP asked me recently if I thought there was an element of ‘up’ as well as ‘down’ and I said not. But SWMBO rather thinks there is, and the more I consider it, the more I come round to the view that she’s right. I guess the pills smooth out highs and lows—every valley shall be exalted, and every mountain and hill shall be made low—but I have a sneaking suspicion that this comes at the expense of a kind of suppression, a feeling that I’m being averaged. There is much more to be described and written, but others were there long before me (Stephen Fry has recently spoken about this). There are many implications for theology, particularly with respect to biological drives and the notion of  ‘made in the Divine image’.

Some people feel that taking happy pills means that they are second-rate humans. I’m not inclined to see it that way: it’s not because we lack something, but because we see more clearly. We need something to cope with the strange society in which we live. Society doesn’t look down on people who take antibiotics, so why should those on antidepressants be sneered at? I am as I am. If I need chemicals, then I need chemicals. If that troubles others, it’s their problem.

I look back over the blogs. Sometimes I think ‘yes, spot on!’ Sometimes I think ‘why did I write that? I wouldn’t write that now’. The things we say and do, and write, are without doubt products of our moods and emotions. We are slaves of our brain chemicals. All of us. There’s plenty in the medical literature that points to a link between creativity and psychiatric illness. There’s the lovely story of a man with Tourette’s syndrome who takes pills during the week for work, but not at the weekend when he plays in a band: he’s a better musician without the pills. The question becomes: ‘how can I make the best of my condition?’

To all fellow ‘sufferers’ let me repeat: what resources would you like to see? What can I do to help? If you’d like to contact me with suggestions, I’ll see what I can do.

Doctor in the house

Professor Sir Stanley Clayton

Professor Sir Stanley Clayton

Dulwich Hospital, late 1974 or early 1975. Teaching ward round led by Professor Sir Stanley Clayton, author of celebrated Obstetrics and Gynaecology undergraduate text. I was not the most diligent of students, but I turned up for everything. Osmosis works.

SC: Tell me, Mr Monkhouse, what do you know of the aetiology of pre-eclampsia?
Me: silence
SC: Well, perhaps you can tell me about its treatment.
Me: silence
SC:  [we wore name badges] Mr Monkhouse, do you have a textbook?
Me: Yes, sir. Yours.
SC: Have you ever opened it?
Siemiginowski_Marie_Casimire_with_childrenCambridge, Addenbrooke’s Hospital, early summer 1975, ‘final’ Obstetrics viva voce examination

Mr Michael Brudenell (examiner): Why might this lady know more about her condition than most?
Me: because she’s a librarian.
MB: Oh, very good. And what advice will you give her about feeding her baby?
Me: Breast.
MB: Tell me why.
Me: Because breast is best. Cow’s milk is for cows, and human’s milk is for humans. There’s no better reason.
MB: Haw, haw, haw. Well I think that’ll do. Off you go.

I passed.

Bennett-Fracture-LCambridge,  Old Schools, early summer 1975, ‘final’ Surgery viva voce examination. I can’t remember who the examiners were, but there were three of them, all professors or Sir somebody or other.

Examiner: Good morning. Take a seat. Which College?
Me: Queens’.
Examiner: And which medical school?
Me: King’s [College Hospital Medical School, London].
Examiner: Haw, haw, a royal flush, eh?! Haw, haw.

After I’d picked myself up from rolling around on the floor in laughter, I was handed a radiograph of a wrist. There was a fracture of the base of the first metacarpal. God knows how I recognized it, but I did.

Me: Ah, a Bennett’s fracture.
Examiner: Very good. Pause. Tell me, who was Bennett?
Me, confidently: a nineteenth century Dublin surgeon.
Examiner, surprised: Oh. Pause. Quizzical look. Was he?
Me: I’ve no idea. I was guessing. There were so many nineteenth century Dublin surgeons, so the chances are good that he was.
Examiner: Haw, haw. Very good.

Ironic, in view of my subsequent history (there must be a God after all), but Bennett was a nineteenth century Dublin surgeon. And there were so many of them. I passed.

Summer delights

allergy-eyes1-300x203

Summer’s leaks

The sun is shining. It’s very warm even at 7.30 am.  Og the dog and his minders are on their way to Togher woods for their morning constitutional. The woody fragrances are overlaid by those of bovine ordure, not unpleasant. SWMBO asks if I see the pretty flowers. Then she looks at me. Eyes running, nose streaming, chest heaving to force breaths in and out. ‘No, I suppose you don’t’. She’s right. Everything is a blur. So is the screen as I type, now an hour after we’re back, and after antihistamines, salbutamol and whatever it is that’s in the dark brown inhaler. Prickly eyes, prickly skin, it feels as if there’s a wire brush down my trachea. Oh bliss, summer is upon us.

Here is an extract for today from http://www.met.ie/: ‘Grass pollen affects up to about 95% of hay fever sufferers. The early-flowering grasses will be reaching their peak during the warm weather this week.’ What a joy. This, I suppose, is why bread makes me feel prickly inside, why whiskey and I have a fraught relationship (thankfully), why cakes and buns are not good for me. It’s kind of people to offer me them when I visit. A couple of weeks ago I took one, had a bite, then surreptitiously put the bun it in my pocket. Later that day when I was foraging for coins to pay the M7 toll I forgot about the bun so there was a shower of crumbs all over the front passenger seat. Still there I think.

My childhood in agricultural Cumberland was blighted by corn, wheat and hay. Going with my father into his flour mill was just not on, any notion of following in his footsteps unthinkable. Playing among hay bales soon demonstrated the law of cause and effect. Funny, though, I kept doing it. Wasn’t it Einstein who said that insanity was doing the same thing over and over again and expecting different results? I knew there was a reason why cold and sunny weather suits me best.

Medical school & interviews

St Mary's said no

St Mary’s said no

Interviewing prospective medical students was always interesting in the old days. By old days I mean the days before interviews had to be structured for the sake of introducing what ‘experts’ called ‘objectivity’. Here’s an exchange from the 1980s.

Good afternoon. It’s good to meet you. I hope your journey was comfortable.
It was aw-right.
And how do you like living in XXX?
It’s aw-right.
Can I get you a glass of water before we begin?
I’m aw-right.
You’ve had a tour of the campus, I think. What did you make of it?
It’s aw-right.

And so it went on. Here’s one from the 1990s.

And what do you enjoy in your spare time?
I watch opera.
How lovely. Which opera are you particularly fond of?
Pardon?
Any particular opera?
Sorry?
I thought you said you liked Opera?
Yea, I did. On the TV every afternoon. Oprah Winfrey.

Honest, that’s true. It rather took the wind out of one’s sails, I can tell you. Hard to keep a straight face. In 1968 I recall a trip on the sleeper from Carlisle to Euston. I arrived in London about 6 am and had to fill in time until the early afternoon for an interview at St Mary’s Medical School, near Paddington station. I thought I’d go to Piccadilly Circus which I’d heard of. I knew nothing of its—let’s say cosmopolitan and relaxed—reputation, and neither was my ignorance challenged that morning. After a breakfast burger at the Wimpy, the height of sophistication, I can’t remember how I filled into the rest of the time but somehow I did. The only bit of the interview I can remember was the beginning. One of the three interviewers (men, suits, how-now-brown-cow accents) said ‘Tell us, Mr Monkhouse, what are you good at, apart, of course, from passing examinations. haw, haw, haw.’ They were, it subsequently became evident, mocking the piano and organ exams that I’d taken periodically since 1963. I was not offered a place. Later that year I had an interview at Manchester where we had a good deal of fun. They kindly said they’d have me if Cambridge didn’t. I think they, unlike the rugger-bugger yahoos at St Mary’s, were entertained by my being an organist.

Queens' said yes

Queens’ said yes …

The admission process for Cambridge was strange. I applied for an ordinary place at Queens’ College as well as an organ scholarship to any college that would give me one, the two processes running in parallel. I was interviewed by the then Senior Tutor of Corpus Christi College, a most urbane chemist (academic, not drug store), who sat me down on the chintz sofa opposite him, gave me a sherry (yes, really) and started a fireside conversation that I recall as glittery and great fun. Though details escape me, Shap fell was mentioned, there was talk of Gilbert and Sullivan and organs (musical), though nothing about medicine. The organ scholarship did not materialize (contemporaries were Stephen Cleobury, Ian Hare, Edward Higginbottom: I was never in that league, though I thought I should be) and although I never actually had an interview at Queens’, the Corpus one must have been passed across, as it were, for after sitting compulsory entrance exams, I was offered a place at Queens’. Escape from Cumberland.

... and so did King's

… and so did King’s

In 1971, it was the normal practice for Cambridge medics to do hospital-based part of the medical course elsewhere. I applied to four London medical schools. I gave St Mary’s the old heave-ho this time. I was turned down without interview by two, turned down after interview by St Bartholomew’s (no recollection other than that it was sticky), and accepted without interview by King’s College Hospital Medical School in Camberwell. So there I went in autumn 1972. Susan and I were married in summer 1973 so I was one of the few married students. I failed the first part of medical finals in 1974 (or was it early 1975?), passed them with the second part in summer 1975. Thus ended my days as an unpaid student.

Towards the end of my time as a medical school academic, interviews became more and more structured until in the 2000s we had to ask every candidate the same questions, and were not allowed to follow any leads. This killed the whole process stone dead; there was no room for exploring, no way of probing, just wholesale encouragement of the initiative-stifling tick-box mentality that is rife. As for any quest for objectivity—pish! There is no such thing outside mathematics. One of the results of structured interviews is that it becomes much easier to advise candidates on what to do and what not to do. If you’d like the benefit of my experience and advice, don’t hesitate to get in touch. My rates are very reasonable, and I could throw in a plenary indulgence or two and an all-purpose blessing.

Medical ‘ethics’?

srgry02Recently I’ve posted a few blogs about what some people call medical ethics. The ‘discipline’ is a fairly recent invention, its having grown as the influence of faith and religion in society has diminished. I enclose discipline in quotation marks because for the life of me I can’t see that there is any coherent discipline whatsoever. To my mind, given the infinite variety of medical scenarios, it’s impossible to distil a discipline. There are too many variables.

Perhaps I’m wrong, and lack vision. Perhaps, on the other hand, I see that the Emperor is naked, and that there aren’t any generally applicable principles. Perhaps medical ethics is an illusory codpiece trying to constrain what should hang free. Medical ethicists have increased the number of –isms (if you’ve seen Ferris Bueller’s Day Off, you’ll know that he doesn’t care for -isms. I’m with him there), one of which, coherentism, is a fancy word for taking all things into consideration in the present circumstances, and ignoring what we don’t like. It resonates with the observation I’ve quoted before of Fr Herbert McCabe (1926–2001), a Roman Catholic priest and philosopher, that ‘ethics is entirely concerned with doing what you want.’ Hitler had an ethical code: it just wasn’t one that gains much favour today. I wonder how many ‘medical ethicists’ have been at the sharp end—bedside, operating theatre or surgery. How many have been patients with serious illness, or parents of those with serious illness?

Thomas Merton wrote that the gospel message ‘becomes impertinent and laughable if there is an easy answer to everything in a few external gestures and pious intentions. Christianity is a religion for men who are aware that there is a deep wound, a fissure of sin that strikes down to the very heart of man’s being.’ Rowan Williams writes that ethics ‘is a difficult discovering … of what has already shaped the person you are and is moulding you in this or that direction.’ And there, I think, we have it: whatever ‘ethicists’ say, ultimately the resolution of every dilemma comes down to one or more decisions by an individual. An individual makes decisions not on the basis of texts that someone else has written or –isms that someone else has invented, but on what has shaped and is shaping his or her psyche.

For me, compassionate pastoral action matters more than anything else, and this is as true in ministry as in medical practice. Compassionate pastoral action means prudence and 360˚ watchfulness. It means considering the needs of community. It means self-forgetfulness. It means accepting that I will get things wrong, and this is something the public seems unwilling to tolerate. It means humility—knowing my place on the earth, humus.

Confidence and integrity come not from choosing from someone else’s menu of options, but from sifting out what’s appropriate to the truth of my being, and of the situation in which I find myself. If I call myself a Christian, I must attempt to model my life on Christ’s. That doesn’t mean living a life like his, but rather living my life as authentically for me in my circumstances as he lived his for him in his circumstances. If we could encourage medical professionals along this road, I would be cheered. If we could get people of faith to engage more with those at the sharp-end of medical decision-making, and vice versa, I would be thrilled.

Jensen

800px-Jensen_FFCardiology outpatients, some time in 1974. The consultant, now long gone to his reward, is an extremely eminent Harley Street cardiologist, pinstripe, bow tie, the works. The patient is a young lad with a heart condition. He is accompanied by his father, an artisan with a pronounced sarf Lunnun accent.

Consultant: Now, tell me my good man, what’s the young chappie’s name?

Father: Jensen, boss.

Consultant: Jensen, eh. That’s a most unusual name. How did you come by it?

Father: Well, yer see guv, we like cars, and a Jensen’s a fantastic machine, and it seemed like a good name to me and the missus.

Consultant: Oh, I see. That’s rather good. Pause. I must say, it’s as well you don’t like Fords. Haw, haw, haw!

Maybe you had to be there.