Like most doctors I have read and am a fan of Samuel Shem’s House of God, with my favourite Rule being Rule 10: “If you don’t take a temperature you can’t find a fever.” If you don’t intend to treat any fever you find then why look for it? This goes hand in hand with Rule 13: “The delivery of good medical care is to do as much nothing as possible.”
This sentiment is echoed by good physicians as the perennial and sometimes annoying “but how will that alter management?” response to a suggested plan of action. In short, plan your investigations in advance and don’t do any test unless the result determines what you do. Otherwise you might lead yourself up a diagnostic dead end and either have to retreat, admitting your test was useless, or be forced to advance down a suboptimal route for the sake of pride. Or worse, you get stuck and no progress is made due to diagnostic and therapeutic confusion.
This rule was followed most impressively by a Yorkshire medical retina specialist at Moorfields. At a place with all the best diagnostic equipment and treatments in the country he would only do what was needed and his patients loved him more dearly than their own kin. As his clinic progressed he would wander around his well-oiled team, chat to the patients and staff and did the equivalent of three hours of stand-up comedy while, in fact, keeping a careful eye on things and ensuring the clinic was shipshape and Bristol fashion. He would rule his clinic with a rod of iron and would often get annoyed if tests were ordered that would not have a direct influence on clinical care. If a fellow ordered a spectralis ocular coherence tomography scan in particular, or an indocyanine green angiogram, his response would usually be catastrophic. If you had walked into his clinic late, naked and then proceeded to urinate over his desk the reaction I imagine would be pretty much the same. Tests have morbidity and mortality. Patients are people not opportunities for research. Communication with the patient was key, not communication with the imaging department.
“Communication with the patient was key, not communication with the imaging department.”
I was working on his firm when the junior doctor strikes took place in England and I informed him I would be taking part. This was my last opportunity to help the junior doctor cause before I was made consultant and a good opportunity to stand up for socialism and the NHS and lots of other nebulous good causes. I expected, with his northern roots, that he would be strongly supportive but although he sympathised he could not see how anything good could come from striking. In fact he was quite dismissive.
I struck on every strike day, stood at the picket, endured the loss of pay and defended the cause to other ophthalmologists in the canteen and in clinic. It was quite nice to feel part of something big. The best bit of the whole experience was when I met all three Plaid Cymru MPs on Westminster bridge during the march and listened to Jeremy Corbyn speak. This was socialism in action and I felt my discussions with groups of people in the canteen and via the fellowship Whatsapp group had in some way real influence on the greater good, though I might have been quite mistaken and people may have actively avoided me or hidden their decision to work for fear of being verbally attacked by a left wing Welshman.
There was a new and better contract drafted and a vote held. The government had been scared and would think twice before pressing for further ill considered ‘reforms’ aimed in reality at dismantling the NHS. I thought of Nazi troops calling off their invasion plans after the RAF mauled their Luftwaffe so badly during the Battle of Britain. So, fair enough, London and other major cities lay in burning ruins and tens of thousands were dead but Operation Sealion would not take place. The nation saved.
As you know the reality was different. The new contract was voted down amid calls by junior doctors for further concessions and the movement began to fragment. Johann Malawana the chair of the BMA junior doctors committee resigned and was replaced by Ellen McCourt who first pushed for greater strike action further splitting junior doctors apart, then cancelled all strikes and went to ground with very little communication for months, other than to send out a pile of much derided stickers with ‘At work against imposition’ written on them. The junior doctor committee was paralysed and eventually the strikes were officially called off. Instead of a victory, the government forced to draft a new contract due to a united front of junior doctors, there was a defeat as unimpressive as the stickers. Not even a defeat with honour. The whole thing just ran out of petrol. In public. On the motorway. With no effort by any of the occupants of the car to either refill the tank or call the AA. The junior doctors committee just sat there or invited people to email the car manufacturer. I kept quiet in the canteen, or just ate food like a more normal person.
As I nursed a coffee during my last week at Moorfields I was approached by the Yorkshireman who wanted to wish me well and we had a good chat. We discussed the strikes and he laughed at my naivety. “That wouldn’t have happened in my clinic,” he said. He was right. It was against the principles of good medicine; temperatures were found when no treatment of fevers was planned, investigations that did not alter treatment were undertaken and patient communication was appalling. The end game was the equivalent of a fellow sat paralysed at their clinic desk staring wide eyed with fear at an angiogram they did not understand and for which there was no known treatment, while ignoring the pleas of the patient and their relatives who would occasionally try to attract their attention from the waiting room. I could tell he had predicted this from the outset, with his northern wisdom made all the more powerful at being so unaffected despite a lifetime of work in the Big House. If I had a sticker with me at that moment I would have given him one.