The approach to many hospitals is blighted by an oncogenic miasma of second-hand smoke. It’s less of a problem than it used to be, but even now I pass wheelchair bound patients coughing over a fag at eight in the morning. Depending on which entrance I use, there may be a sign above their heads saying ‘STRICTLY NO SMOKING’. My reluctance to tell them to stop, or to move beyond the hospital’s boundary, says something about my identity at work.
If this was a restaurant, a train or a shop I would be the first to face them and ask politely that they stop. If there was no response, my natural reticence would do battle with my genuine annoyance/anger, and between them would work out whether I remonstrated or turned away – the older I get the more likely I am to escalate. But not with the smoking patient. Why?
It is because they are patients. What I want to say is, ‘Put that cigarette out. You know you’re not supposed to smoke here. Why shouldn’t you obey the rules? And don’t tell me you can’t go out because you’re in a wheelchair… one of the others here could take you.’ If no response, a part of me would want to continue, ‘You make this end of the hospital look horrible, why should all these people coming to work have to meet a cloud of smoke first thing in the morning… and look at all the butts on the ground, smoking doesn’t automatically give you the right to litter…’ And then, the transgression – a moral judgement, ‘Anyway, you wouldn’t be in here with this [amputation/heart problem/lung problem] if you didn’t smoke.’ This being said entirely without evidence, but as a manifestation of my frustration.
Yet even to ask them to stop or move is uncomfortable, because in doing so I am breaking out of the role of doctor, who strives to understand patients and shies away from criticism. Addiction is to be met with sympathy, allied to an agreed and constructive strategy to reduce it. When an alcoholic patient of mine returns to the ward carrying the smell of vodka, I am exasperated, but I do not criticise. That will do no good. Behaviour is challenged if clearly anti-social, but not overtly vilified. Doctors don’t come to work to tell people off.
So the doctor looks at the smoker, tuts, and moves on, leaving any correction to the security patrol who will surely pass by in half an hour or so. They, I hope, will not be inhibited by the instinct, magnified by training, to empathise and understand.