Reviews: Vivien Horler
Your Life in my Hands: A junior doctor’s story, by Rachel Clarke (Metro)
The Human Kind: A doctor’s stories from the heart of medicine, by Peter Dorward (Bloomsbury/ Jonathan Ball)
The two doctors at the centre of these books are both active in Britain’s National Health Service. Rachel Clarke is a “junior” hospital doctor in her late 30s based in London; Peter Dorward is a much older GP in Edinburgh.
Clarke’s book, which came out late last year, is perhaps the more political of the two. She worked as a current affairs TV journalist for around 10 years before training as a doctor, inspired partly by her doctor father to whom she dedicates this book.
I think that from the South African perspective we tend to think the NHS is a wonderful institution compared with the local public healthcare system. And of course in many ways it is.
But Clarke says from the medical staff’s point of view understaffing is at best exhausting and at worst soul destroying. Apart from the danger this exposes patients to, she says another casualty of doctor overstretch is the one that attracted them into medicine in the first place, “our kindness”.
“People say the NHS runs only on the goodwill of its staff: the doctors, nurses and allied healthcare professionals who are willing to go the extra mile not for money, or thanks or praise… but for the intrinsic rewards of helping a patient. If that’s right, then working conditions that grind away relentlessly at our capacity for kindness threaten the survival of the NHS itself.”
In 2015 Britain’s secretary for health, Jeremy Hunt, announced that the NHS was suffering because some doctors were refusing to work over weekends. This meant, he said, that if you were admitted to hospital over a weekend, your chances of care or even survival were not as good as if you were admitted on a weekday.
Clarke concedes there is some truth in this: while accident and emergency departments are equally staffed each day of the week, most hospital in-patients are looked after “by a skeleton crew of doctors whose main objective is to attempt to keep their patients safe until Monday morning, when full routine services resume”.
But what the politicians of the time were not saying was that while they wanted the health service to be as good on a Sunday as it was on Monday, they weren’t prepared to increase resources. And the doctors said you couldn’t have a seven-day service on five-day funding.
“Without additional medics, there were only two ways to roster more of us at weekends: either take us away from our patients Monday to Friday, or force us to work longer overall hours. I failed to see how either option could possibly have patient safety at its core.”
Eventually, for the first time in 40 years, junior doctors went out on strike.
The book is a mixture of measured argument, anger and medical case files. It is also a warning to South Africa that if a national health system is not properly funded, it will fail. Wealthier people – perhaps fewer than is now the case – will still go private when necessary, leaving the vast majority in a cash-strapped system to long queues and waiting lists for everyday yet potentially life-transforming surgeries like hip and knee replacements, and cataract surgeries.
The Human Kind is more reflective. Peter Dorward is a thoughtful doctor, in fact he accuses himself of tending to “over-think” situations.
He too is always rushed, always has too many patients waiting to see him. But he has a lifetime of medical experience, and has learned many things not taught in medical schools: how to break bad news, how to answer the question: “How long have I got, doctor?” And one of the toughest of all: “I don’t want to go on living like this, doctor. Can you help?”
He writes about the ethical dilemmas doctors face every day; about the desire of a doctor to be “good”, to do the right thing, to be caring and compassionate, even to patients who he doesn’t like, and who are making no effort to look after themselves. Or the people who are mysteriously ill with a variety of symptoms, none of which seems to have central cause. Eventually even the most saintly of doctors may lose patience, may suggest that what is ailing them is “in your head”.
But this of course is extraordinarily offensive, writes Dorward, as it translates as “not real” or “made up”. It makes a liar of the sufferer.
And then there is dealing with intractable pain. It is very hard to imagine another’s pain, and the scales doctors use – how bad is your pain on a scale of one to 10? – are not much use because every patient is different.
Dorward writes about the over-use of painkillers and opiates; how they can help to begin with, and then often make a patient sluggish and depressed. At what point do you prescribe, and at what point do you stop?
Sometimes Dorward thinks that strange differentiated symptoms and even pain can be caused not by illness but by simple loneliness.
Much of The Human Kind is about Dorward’s philosophy of health and of medicine, interspersed with plenty of case studies. He also describes breaking his ankle badly during a mountain climbing incident, and the insights his treatment brought to his own practice of medicine.
Two interesting and enlightening books.
- This review has also appeared in Weekend Argus on Sunday on April 15, 2018