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Sophie: Bye. Love you!
Mark: I love you, too. (It’s okay, everyone says it. I say I love Häagen-Dazs and my broadband provider, and I like Sophie more than them. In most respects.)

 

Yes, Valentine’s Day is fast approaching again and for my opening gambit I have used another quote from the sitcom Peep Show. In this scene, Mark says goodbye to his girlfriend Sophie and justifies the use of the word ‘love’, reassuring himself that it tends to be a throwaway word nowadays. I can agree with him; I love what I consider to be the king of crisps, Frazzles, and I also love my Bluetooth speaker.

However, they can both let me down at times and I don’t love them quite as much. Sometimes the bacon flavouring on my bag of Frazzles isn’t up to par and they taste a bit bland. Occasionally my smartphone will not connect to the speaker and I have to resort to turning everything on and off again or waving my phone frantically around the room.

Ever since the first day of medical school I have had an on / off love affair with medicine as a career. There are moments which I have truly loved which include my medical student elective in Australia and there are times which I have absolutely hated such as my episode of burnout when the Dementors circled above me. This article will therefore be a discussion of some of those bitter-sweet moments of my career.

The highlight of my first year at university has to be Rag Week, towards the start of the summer term. It was some much-needed escapism from the relatively intense studying in the lead up to the end of year exams. The threat of failure leading to the dreaded re-sits loomed heavy over us. But there was much fun to be had beforehand in this week of various events raising money for charity. Many of these would probably not be acceptable in today’s climate – one of which was the Hit Squad. For a small fee, one could pay this appropriately named group made up of members of the rugby club to take out a ‘hit’ on a fellow student of your choosing in the cafeteria. After payment, they would enter the large room dressed in sunglasses and wigs with cream pies walking around looking for their victim. Everyone was in suspense hoping it would not be them, before they gathered round their target and the hapless person received multiple pies in the face.

I naturally decided that I would pay for a hit on my close friend Maxine. After payment I returned to the lunch hall and waited, looking on with a satisfied grin from a distance. When the Hit Squad entered, I was confused when they sailed past her. With utter shock they proceeded to form a circle around me and I received all the pies in my face. I discovered afterwards that having been tipped off that a hit had been taken out on her, she had paid a supplement for it to be reversed. She was laughing heartily as I was pulling the remnants of dried cream from my hair for the rest of the afternoon during the physiology practical.

The preclinical years seemed to last an interminably long time and we were all desperate to finally get onto the wards and start seeing patients. In the autumn of 1992, I excitedly attended my first respiratory teaching ward round. I was so proud, wearing my white coat and felt like I was finally on my way to becoming a doctor. We were gathered around a patient with an infective exacerbation of chronic obstructive pulmonary disease and the consultant asked me to auscultate his chest. I pulled out my red nurse’s single-head stethoscope, which I had been given by a family friend over the summer in preparation for my time on the wards. As I moved to the side of the bed the consultant stopped me and said, “Where did you get that, out of a cornflakes packet?” There were a few stifled laughs around me and a wave of embarrassment engulfed me. The very next day I went straight to Wigmore Street to buy a black Littman bell and diaphragm stethoscope. However, this was the first of many humiliating moments that were to punctuate my clinical medical school years.

Once I had started on the ophthalmology career pathway in the late 90s, my main goal at the time along with every other senior house officer was to become an accomplished cataract surgeon. It wasn’t without its stresses learning to perform an operation which was potentially blinding as a complication. However, the enormous sense of achievement after each successful procedure was remarkable. Once again, I felt I had made it. I was well and truly on the path to becoming an eye surgeon.

The main milestone at that stage of my training was to reach the first 100 cataract operations. For my 100th case, the staff in the operating theatre looked on as the unflappable associate specialist assisted me. Yes, you guessed it, I ruptured the posterior capsule during irrigation and aspiration. My ever-forgiving colleague guided me through my first anterior vitrectomy. At the end, the staff handed me the card they had prepared for me in advance with a small last-minute addition: “Congratulations on your first 100 cataracts + 1 anterior vitrectomy.” Like many England World Cup matches I have watched, I snatched defeat from the jaws of victory. My love / hate relationship with cataract surgery continued into the consultant stage of my career, with the reward of improving a patient’s vision being finely counterbalanced by the stress and turmoil from the occasional complication.

As I have mentioned previously, one of the most satisfying and rewarding aspects of working in medicine is patient communication during face to face (F2F) consultations. Only very recently one of my longstanding partially-sighted macula patients had me laughing out loud in the clinic when she narrated an interaction with her regular taxi driver on the way to the hospital that morning:

“There’s something I need to tell you, Mrs Smith,” the taxi driver said.
“What’s that?” she replied. “I’m the most handsome taxi driver at City Cabs.”
“Oh really?” she said.
“Yes,” he confirmed, “and I’m telling you this because I know you cannae see me!”

Sometimes patient interactions can be challenging and are not quite as enjoyable especially when breaking bad news or discussing the complications from the outcome of treatment. On the whole though, F2F reaps benefits for both the clinician and patient especially in building trust and rapport, allowing for a holistic assessment and being a much richer form of communication addressing any non-verbal cues.

However, there has been a gradual erosion of the F2F patient consultation in order to cope with the overwhelming workloads and that is with the rise of the virtual clinic. They have gradually filtered into ophthalmology practice over the past decade, and now appear to be with us to stay especially in the management of glaucoma and medical retina conditions such as age-related macular degeneration and diabetic retinopathy. They have also been taken up by many other branches of medicine including endocrinology, psychiatry, dermatology and rheumatology.

Some of these virtual clinics do not even involve any direct communication with the clinician, but rather a patient’s test results being assessed remotely and a treatment decision being communicated to the patient by letter. These virtual clinics increased exponentially with the arrival of the Covid-19 pandemic, with the additional benefits of social distancing, such that clinicians have become ever more distanced from their patients.

There is something though that as clinicians we are losing with the rise of the virtual clinic and that is the fundamental soul that lies at the heart of practising medicine which is in direct human interaction. It is clear now over the past couple of decades that there has been a dehumanisation of modern healthcare, with the unfolding of a more industrial ‘scientific-bureaucratic’ medicine. However, medicine is not only about diagnosing and treating disease, but also about the holistic and personal approach to providing care involving empathy, touch and human reassurance and understanding [1].

 

 

The movie Jerry Maguire (1996) sees Tom Cruise playing a sports agent who, following criticism from a client, has a life-changing epiphany. He becomes disillusioned with the sports management business and writes a mission statement with a desire to work with less clients but providing a more personal and caring relationship. At the start of Jerry’s mission statement [2], he writes: “There is a cruel wind blowing through our business. We all feel it, and if we don’t, perhaps we’ve forgotten how to feel. But here is the truth. We are less ourselves than we were when we started this organization.” He continues later with: “We are losing our battle with all that is personal and real about our business.” He finishes with the line: “The secret to this job is personal relationships.” It is worth reading the statement in full and substituting the words ‘sports management’ for ‘medicine’ to see the similarities [3].

In response to the statement, Jerry Maguire is fired. As he leaves the office to start his own agency with a more personal approach he asks if anyone will join him. Ultimately, he departs with only Flipper the goldfish and one of the secretaries. I believe that as clinicians we should try to return to the more personal F2F approach to medicine that we have been trained for. Who will join me and Flipper as I leave the hospital having been fired by management when I suggest this?

Returning to the title of this piece, ‘Love will tear us apart’ – this is a song by the band Joy Division, written by the lead singer, Ian Curtis [4]. The lyrics were inspired by his marital problems and are a tribute to a dying relationship. One of the lines reads: “When routine bites hard and ambitions are low and resentment rides high, but emotions won’t grow and we’re changing our ways, taking different roads... then love, love will tear us apart again.”

With the advent of this dehumanisation of modern healthcare and all that we have lost along the way in the personal relationships with patients, I hope that our love for medicine does not tear us apart again.

 

 

References

1. In a recent conversation with the physician, broadcaster and comedian Dr Phil Hammond, he asked: “Do you know what the most powerful drug in the world is?” Phil’s answer was: “It’s kindness. It works for absolutely everyone – it’s free at the point of delivery and it’s very hard to get the dose wrong.”
2. Jerry’s mission statement can be read here:
http://www.theuncool.com/films/jerry-maguire/jerrys-mission-statement/
3. Love for the job is something I have always pondered on and Jerry’s mission statement also has the following to say on this subject: “I am wondering what that exact moment is when we truly, truly love our jobs. Is it during the day, or at the end of the day, or is it years later looking back on all we accomplished? I think perhaps truly loving something is the ability to love it at that moment.”
4. Love Will Tear Us Apart was named as the greatest single of all time by the music magazine NME in 2002. Worth a listen, but maybe not on Valentine’s Day.

Check out the Pete’s Bogus Journey ‘Love Playlist’ on Spotify here:
https://bit.ly/4h3jfDQ

 

 

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CONTRIBUTOR
Peter Cackett

MB BS (London), BSc (London), FRCOphth, Princess Alexandra Eye Pavilion, NHS Lothian, Edinburgh, UK.

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