Month: July 2018

The Choice, episode 4/6: Invitation

 

So, Jeremy Stackson had died, aged 82. Well into retirement. Jessica found an envelope in her wire tray. She was invited to an event – not a memorial as such, more an after-memorial appreciation, to be held in the hospital’s postgraduate centre one evening. Food, wine. As a local practice lead and administrator, somebody thought Jessica should be on the list.

The idea chilled her. Of course, he would not be there, and to go would show respect for all the work that he had done during a long career. But to not go… well, would anybody really notice? To do so would be petty, and beneath her. How likely am I, she asked herself, to open up about the way he made me feel that day? Not very. But a part of her would want to. Or at least, make oblique comments like, ‘…but he didn’t suffer fools did he?’ or, I was his trainee once, he had a real go at me…’ She imagined the understanding looks, for his reputation as a difficult man was well established, even if his reputation as a tenacious innovator who tended to get his own way out-shone the darker side.

No. To go would be hypocritical. She didn’t like him. I’m 57, she reflected, I don’t have to do anything.

At the next practice meeting the invitation was discussed. Another partner, Christopher, felt it was important that the practice was represented. Jessica was the natural candidate. The room looked at her. She made a non-committal reply. Later, the fellow partner commented,

“Jessica, you looked pretty uncomfortable when we were talking about Jeremy Stackson’s memorial thing.”

She paused. All the rationalisation, all the ‘putting it behind me’, all the genuine happiness in her professional and personal lives fell away, as she replied,

“No. I can’t go. He single-handedly ruined my surgical ambitions. Didn’t I ever tell you…?” and she told Christopher everything.

“But you’ve made such a success of this life. Do you really regret not being a surgeon?”

“No. I make it a policy to regret nothing. But it should have been my decision.”

“It was, wasn’t it?”

“No. The realisation that I was or wasn’t suitable for a life in surgery should have come from within me.”

“Sometimes we need people to put the mirror in front of us. Like you did with what’s her name, that trainee, er… Helena Banks.”

“Not in the way he did. He destroyed me, in front of everybody. He was foul.”

“Mmm. I guess we don’t want you telling that to his friends.” Christopher laughed.

“Or his wife,” added Jessica.

“No, she passed away a long time ago. By the way, regarding Helena Banks. I hear she’s one year away from becoming a medical consultant.”

They both looked skywards, sharing the same thought. God help her patients.

“So that’s final is it? You won’t go?” asked Christopher.

“I can’t. I’ve spent so much time hating him. And it hasn’t abated.”

“You know, in his mind, that interaction with you was probably nothing. He didn’t even remember you when you met later. It was nothing. Put it aside. Life is too short.”

Jessica thought about it, hard.

***

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The Choice, episode 3/6: Trainee

 

Not all the trainees that came to work with Jessica, now 47, were good. One, Helena Banks, appeared incapable of concentrating for more than forty-five minutes, and had such a ‘direct’ medical approach she habitually missed clues given by patients. Despite all the training, she had not developed any real sensitivity to non-verbal signs, nor an engagement with the emotional side of the job. In Helena, Jessica saw something of her own approach in the early years, when she focussed overmuch on finding pathology, rather than seeking to understand the patient’s response to disease and helping them manage it. Yes, you needed to be a diagnostician, but once the disease, if found, had a name, you had to carry on, and remain engaged. Well that was Jessica’s idea of being a GP.

They met, as trainee and supervisor, and Jessica found herself getting increasingly annoyed. Helena had no insight. She thought she was doing pretty well. Jessica described her observations and how she thought Helene could improve. It didn’t go down well, but nevertheless Helena agreed to try to adopt some of the approaches suggested to her.

The following week Jessica supervised a morning list. A 36 year old father came in. He had been complaining of stomach pain for three months. After three visits, another GP had arranged for him to have an endoscopy at the hospital. All clear. Good news. And here we was today, coming for more advice. Jessica knew this man’s story. He had lost a child to a rare tumour three months before the pain came on.

Helena read through the report. She actually used the words, ‘Good news!’ Nothing wrong here. Sensitive stomach. Nothing more to do. She wasn’t rude, she wasn’t too fast, but she missed the point. It was all related to the man’s bereavement.

Jessica let Helena continue, and watched the poor man leave. As Helena moved to call in the next patient Jessica intervened. She needed to talk. Now.

Helena looked unimpressed by her trainer’s insistence that she should have delved more deeply into the man’s story. What was happening at home? Were there other children? Did the family receive counselling? Was there anything more that could be done? The pain was a manifestation, surely, of the tragedy.

But Helena glanced out of the window.

Is there somewhere you need to be! Jessica almost shouted. She knew now, Helena could not do this job properly. It was time for someone to tell her. She responded only to the most direct approaches.

“Helena. I think I should do the rest of this surgery.”

“Why?” Animosity there.

“You’re… I’m not sure you have taken in what we spoke about the other day. About looking under the surface…”

“You’re saying I’m not a good GP.”

“I’m saying there’s still a lot of room for improvement, outside your diagnostic skills. We can work on it further… but sometimes, it’s necessary to stand back and ask yourself… would you really enjoy a career in this type of medicine? You are still very early on and have options…”

“You think I should give up?”

“No. But I think you need to consider carefully, it’s your entire working lifetime…”

But Helena knew what Jessica meant. And Jessica, having said goodbye to Helena for now, looked up at the ceiling and blew out through pursed lips. God, that was hard.

Only later, during the last consultation, did it dawn on Jessica that she done to Helena as Jeremy Stackson had done to her. Blown her off course. Her words had been delicately silvered, her delivery more thoughtful, but the message was the same. You’re in the wrong game here. You don’t have the equipment. It’s time to leave.

Hard words in a hard world.

***

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The Choice, episode 2/6: Presentation

 

Ten years later, when Jessica described her route to partnership in general practice she did not dwell on that early ambition to be a surgeon. It was almost a cliché; too tough, too competitive… not compatible with life, la la la. Perhaps it hadn’t been a true ambition, more a flirtation. GP was a positive choice. And she was good at it. In fact, her ongoing engagement with hospital-based specialties had drawn her into a role at the Clinical Commissioning Group, where she was helping to develop strategic targets for local surgical development. She was 37.

But… but, she found herself wondering now and again, what would it have been like to plan those operations, to revascularize legs, deal with aneurysms? Not to put too romantic a spin on it, to save, directly, the odd life. The operations in which she had assisted fed her self-confidence and encouraged her to aspire. Other consultants had praised her. Until… Stackson.

Was it weak to have been pushed off course so easily? Did her decision to change the direction of her career reveal an underlying psychological weakness? These reflections only intruded when correspondence bearing his name, so redolent with arrogance, crossed her desk. For Jessica’s Practice lay just within his hospital’s referral area.

And now, look, another type of correspondence… a proposal to the CCG that it commission a novel, high-tech vascular intervention. Driven by him; J Stackson.

Given her interest in secondary care innovation, the surgical services committee chair had passed it to her for comment. For her decision, in effect.

Goodness! What goes around comes around. The circle of life.

There was to be a meeting. Stackson would be giving a presentation.

How old must he be now, Jessica wondered. She was 27 back then, he must have been what, mid-50s. So he was now in his 60s and not that far off retirement, she guessed. But still active, clearly. Still innovating. A force of good perhaps, overall.

She vowed to keep an open mind

*

If Stackson did recognise her, he showed no sign. They shook hands before the committee took seats, he made eye contact with her, as a key decision maker, during the presentation, thanked the committee for its attention, and left.

Then came the discussion. Jessica could not approach the weighing up of costs and benefits dispassionately. Stackson’s voice was echoing in her mind. She dwelled on those tones and inflections, samples of which she remembered hearing during that terrible dressing down ten years ago.

It came to a vote. She voted emotionally but tried to rationalise it. Yes, the proposal was a good one, but… leadership. That department’s track record, under Stackson’s direction,  was not quite… collaborative enough.

“I find too much duplication with similar services in the region,” she said, quietly. The unspoken reservation understood by her colleagues was that the proposal was mainly reputational. The Trust needed this service to be on a par with other vascular units. But the community didn’t.

Stackson’s proposal was rejected.

***

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The Choice, episode 1/6: Ward round

 

 

This series was going to be called ‘The Insult’, but one of my favourite authors (Rupert Thomson) has already taken that title. The Choice is about a female doctor who experiences a severe knock to her confidence from an insensitive, bullying consultant. It spans five decades, jumping a decade between each episode. An alternative ending owes something to The French Lieutenant’s Woman. This is fiction, and a stretch for the writer, because a) I am not a woman and b) I haven’t been seriously undermined like this, but it is based on observation and I hope there is some psychological verisimilitude.

 

*

 

Jessica Paley, 27, a surgical registrar in her second year of specialist training, turned up at 7.30 AM to prepare for the 8 AM ward round. She updated the list of patients, checked the results of recent investigations, and rehearsed the ‘headline’ with which she would summarise the condition of each to Mr Jeremy Stackson, consultant vascular surgeon. He had a reputation for high expectations and a short fuse; he was, Jessica suspected, essentially an old-fashioned male chauvinist, though he was probably very nice to his wife, if he had one. Jessica didn’t know. She didn’t much care. She had seen flashes of venom (including an impatient sulk while he watched her sew a femoral-popliteal bypass recently – too slow, it seemed) but she was confident that she knew how to navigate around the sharpest rocks.

The ward round went well, until they entered the penultimate bay. Jessica spotted the frail, pale old man before Mr Stackson did. She recognised the smell of ischaemia, of black extremities, of urgency. Stackson turned to Jessica,

“Who is that?”

“I… I don’t know.”

“Who admitted him?”

“I… he wasn’t on my… I wasn’t informed.”

The nurse in charge of the ward, Dennis, appeared, nervous himself having missed the larger part of the ward round.

“I do apologise Mr Stackson, this patient was transferred overnight from East Cleverton, apparently you had accepted the referral. He needs a fem-fem crossover, the notes he came with say.”

“And has he been clerked?” He was looking at his SHO.

Jessica felt the base of her gut contract and chill.

“No Mr Stackson. He hasn’t… I wasn’t…” But he wasn’t either; wasn’t interested. A tide of annoyance that had been rising through the morning, perhaps through the last two months, now broke in a wave of invective. His volume followed an upward gradient.

“Disorganised! The whole firm. He’s been in hospital how long, eight hours? and none of you have seen him, its UNACCEPTABLE…”

“I’m sorry.”

“I don’t want apologies. I want an efficient, safe, team Jessica. My entire list now has to be reorganised, to fit this man in tomorrow. You’re clearly not in control, after two months, you’re not in control. Transfers are your responsibility. This is surgery. You are way too passive for… for this.” He flung his arm out to indicate the ward, but he meant this specialty, this life, this future… Jessica knew exactly what he meant. As he moved towards the frail man’s bay, he muttered, as though trying to control himself but only partially succeeding, “For God’s sake, get a GRIP!

Stackson saw the patient and made some decisions. After he had left the ward, Dennis tried to comfort Jessica with words like ‘everyone sees that side of him once…’ and ‘It’s not you, it’s the department…’ but Jessica stopped him. “Why didn’t you tell me there was a transfer? Nobody told me. I been here since 8 o’clock, I could have clerked him.”

Dennis had no explanation.

That night Jessica made a decision. Surgery was not for her.

***

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