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“And Cain said unto the Lord, my punishment is greater than I can bear. Behold, thou hast driven me out this day from the face of the earth; and from thy face shall I be hid. And Cain went out from the presence of the Lord, and dwelt in the land of Nod, on the east of Eden.”

Medical retina fellows at Moorfields are expected to do what is called an ‘outreach clinic’ in a peripheral hospital in London one day a week. Whereas the clinics at City Road are very well staffed and underbooked by traditional British standards, the peripheral clinics are usually booked with more patients to be seen per doctor.

In Wales we had around 12 patients booked per doctor while at City Road this figure could be as low as five or six. Clinics never finish early, however, as the complexity of the patients and need for Ancillary testing and the limitations of getting timely optical coherence tomography (OCT) scans and angiograms is such that the number of doctors is never the rate limiting step; a concept utterly alien to a provincial ophthalmologist such as myself. Much is therefore learnt during clinics at City Road as there is time to discuss cases and ponder the peculiarities of shadows on OCT scans that we would usually ignore as being irrelevant to the direct clinical care of the patient in more normal less blessed places.

The same is not true of the outreach clinics. These are much more service orientated and the unspoken truth is that these clinics are our moral payment as fellows to Moorfields, in order to get to work at City Road. But if the main hospital is like the garden of Eden where groweth trees pleasing to the eye and good for food, these peripheral clinics were like the land to the east of Eden, where man had to work for a living and women give birth in sorrow.

My peripheral clinic was in a place called Hanwell on the outskirts of Ealing in west London. There I found that the notes were arranged, as at City Road, in one big pile from which the fellows took the topmost set. The ratio was much more provincial with around 12 per fellow, but the patients were mostly stable diabetics with far fewer brain bending cases. I have always considered myself a socialist, perhaps even a communist of sorts, but I soon began to reconsider this position after only a short time at Ealing. ‘From each according to his ability to each according to his needs’ just doesn’t work here. The actions of one fellow do not much affect the end result of the clinic as even if a person worked flat out there are simply too many patients for it to matter much. I took a set of notes, saw a patient, typed my letter on OpenEyes and found to my surprise that the next set of notes was the same next set that was there previously. Perhaps the others have difficult cases I thought. Perhaps I had misread the name. Gradually, however, a horrifying realisation was dawning. The majority of the other fellows were treating Ealing as an opportunity to learn rather than pure service provision.

I overheard an American fellow asking the consultant, after waiting in line for 20 minutes for the opportunity to do so, whether an elderly diabetic that had last had panretinal laser 15 years ago and had been happily stable since then should be lasered again. Studies were quoted. Then a registrar asked the consultant if dry macular degeneration was in fact dry. More studies. The new Greek fellow in the cubicle next to mine was having a very detailed discussion about cataract surgery with a Sri Lankan man in heavy accents that made them mutually unintelligible. For 40 minutes. Halfway through the clinic more than half the cubicles were now empty of fellows, although there were patients in each. Fellows queued a long time to ask questions of the boss who would then come and examine the patient and as he moved from cubicle to cubicle the assembled queue of fellows would disperse then reform in exactly the same configuration outside of each new cubicle. The pile of notes unsurprisingly remained stubbornly mountainous.

Then a strange phenomenon occurred. A set of notes I had previously seen on the notes pile and had presumably been taken by someone then reappeared. How was this? Then it hit me like a hammerblow. Some fellows were taking notes, spending time reading them in their cubicles, even bringing up images, then if they found the patient wasn’t to their interest they would return the notes to the pile. The actions of the individual were so unimportant that the industry of one person was not rewarded. Quite the reverse, as those that saw more patients had to endure more unhappy comments from the patient and relatives at the long delay than those that saw so few.

“I don’t know why the consultant was so angry,” the American complained to me as we walked to the tube station. I could barely contain my own anger as I told her she was discussing most of her patients and causing delays. “But I discussed all my patients,” she said looking perplexed. “In the States we have to.” I stopped walking. “This is not the States. This is not City Road. You just can’t!” The Greek fellow was equally confused. “I have to discuss all my patients,” she said. “How will I know what to do if I don’t?”

It was at that moment I first felt that practical socialism was never going to work. It was inherently unfair. We were all treated the same yet had very different functions. “Am I my brother’s keeper?” I asked the uncomprehending Greek fellow. Cain murdered his brother Abel and was expelled to the east of Eden, but perhaps the original fault lies with Adam and Eve themselves for having eaten from the tree of knowledge. At City Road we are taught to question everything through logic and reason to attain knowledge; why should that be unlearnt so quickly just because we are in a peripheral clinic? Perhaps I should be more like Abel and less like Cain; raise sheep and not till the soil. I am Welsh after all. So the next time I go to Ealing I will ask more questions and spend time eating from the tree of knowledge. And I will take my sleeping bag so I can be exactly like the nomads from the Land of Nod. I will need it.

Read more from Gwyn Williams in his book about the comedic misadventures of an ophthalmologist in training The Last House Officer, available from Amazon UK.


The views expressed are those of the author and do not represent those of the editorial team or the publisher.



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Gwyn Samuel Williams

Singleton Hospital, Swansea, UK.

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