Wednesday, July 13, 2016
Making of a Child Psychiatrist: (42) Down to Work Sort of… (2)
It was cold on the scooter going back into London, but I survived without too much trauma; and London has a warmth all its own with millions of people breathing, living and heating up their flats and houses. It was a relief to know I was almost home. Although the temperature was still sometimes in low single figures and there could be frost on the roads late at night and early in the morning, at least it had not rained on my journey back from Plymouth.
Our flat was within walking distance of King’s, 20 minutes through Stories Lane, onto Grove Lane and then Champion Grove, past Dulwich railway station opposite the Salvation Army’s William Booth Memorial College onto Denmark Hill. So Jan had been walking to work. But with me back, on most mornings we took the scooter, which behaved itself in all weathers, and was easy to park at the Med School, and in the road outside our flat. We got into some sort of routine; and it was such a relief to be back home with the one I loved.
Lectures continued, as did clinical casework followed by ward rounds and outpatient clinics under close supervision of registrars and occasionally consultants. In clinic, the idea was that we ‘clerked’ a patient referred by a general practitioner or from another clinic. That is, we went through the history, clarifying details and did a focussed examination, reporting a short synopsis of our findings. The registrar would then double check our findings, and discuss treatment options with the patient. Consultants did not see all the patients, but if there was anything tricky, they were called in. Most registrars were easy to work with, and I rarely ran into any sort of conflict, though several of my colleagues reported running battles. You have to learn to do some strange things as part of the human body examination, and it was in one of the outpatient clinics I first learned how to do a rectal examination and interpret the findings. The headed letter from a local doctor said cryptically “Abdomen: please see.” I took the history of occasional rectal bleeding (noted especially when our patient had been constipated), went through a history related to other systems in the body, and then reported my findings so far. The registrar sought permission from the patient, donned a glove, and then did his examination. There were some small haemorrhoids, and he thought I should feel them. I put on a glove, used the lubricant provided, and followed instructions trying hard to focus on the objective rather than the feel, or the possible discomfort for the patient. Yes, I could feel the fullness in two places roughly at 4 o’clock and 11 o’clock (that is how it is described). I drew a diagram in the notes; the registrar nodded and began to discuss possible treatment strategies with our patient, now upright with his dignity returned. You cannot be squeamish in medicine, but sometimes it takes practice to remove extraneous meanings, and focus on the main game. I will always thank that registrar who passed on the phrase: “If you don’t put your finger in it, you may put your foot in it”. Yes, later we laughed over the phrase, but I never forgot it. Some years later, in general practice, there was to be one spectacular example where a senior colleague had prescribed a cream for his patient’s rectal soreness and bleeding, but had not done an examination. When his patient came to me a few days later with bleeding that was worse rather than better, I could actually feel the edges of the rectal tumour causing the problem, and then saw the fresh bleeding from my gloved examination. He was referred immediately to a local surgeon and operated on within days; he survived.
So, medicine is a practical art. Read about descriptions of illness in isolation and you may forget. Even reading about other people’s case examples, the stories may become blurred over time. “See one; do one” and you rarely forget. Take some responsibility in a clinical situation, be part of finding out about the history and symptoms, find a problem during an examination, and you never forget.
I suppose this is why I found parts of the early psychiatry training so frustrating. I can understand that perhaps a therapist in a deep and meaningful psychotherapeutic relationship with a patient, might not want some ignorant student saying stupid things to their patient or dismissing the symptoms as incomprehensible and therefore not real. But I had always been fascinated by the workings of the mind, had begun to read widely about psychiatry and its history, and thought I was ready to handle it. Perhaps that is when a student is at their most dangerous. After all, as we all know, a little knowledge can be a dangerous thing.
But ward rounds at King’s felt contrived. We rarely met with the consultants; they kept their input to the controlled environment of formal lectures. A small group of us would sit in silence, while a registrar rehashed the symptoms with their patient, keeping it relatively simple and working towards a diagnostic formulation. We were sometimes allowed to ask a single question directly of the patient, but anything considered unrelated or stupid was immediately dismissed by the registrar. The phrase: “You don’t have to answer that question” was in frequent use. I get it; the primary aim is always to first do no harm (‘primum non nocere’). But the process felt so stilted. The alternatives were limited in the 60s. There were a few one-way screens in use, but the use of live video from one room to another was something in the realms of fantasy. It took an awful lot of very expensive equipment to make films with any sort of audio recording. Admittedly, there were round table discussions with consultants that led into psychoanalytic realms, but these were infrequent.
One exception stands out in my memory. I had been assigned to go to the Belgrave children’s hospital with one other colleague and watch some play therapy. The two of us sat in a darkened room behind a screen that obscured more than it revealed. Neither of us was enamoured to be there, and we talked of anything but psychiatry. The view changed as the lights in the therapy room were turned on; clever! A child of about 6 was escorted by a slightly frumpy woman to a sandpit, which he entered. The lady, whoever she was, sat on a stool by the pit and said nothing. The child played, only occasionally looking up at the woman. A bit more confidant, he began to describe some of the action. Perhaps describe is to strong, as what he actually did was to comment on the action, factually, not using any feeling words or explaining what he though was going on. There was a car crash between two cars repeated again and again. Then a mountain of sand was smashed by a toy aeroplane. The plane was taken out of the pit and flown around the doctor’s head and then back into the pit. The doctor did not flinch. No comment was made. As the process evolved, the child directed the doctor to hold an object; that was then retrieved to be used in the next scenario.
We watched perplexed. A couple of times we looked at each other, asking quietly what it was all about, and then checking our watches. Would this boring torture never be over…?
As the process evolved, the relationship between doctor and patient warmed. The child began to ask questions that were answered briefly and gently. Sometimes the doctor would gently ask the child what they thought the answer was to their own question. The play was never directed, but the violence disappeared, the random nature of the actions began to become some sort of repeated story.
The kindly doctor finished the session, suggesting a further one the next day. The boy looked pleased. A few minutes later she appeared in our darkened room, flicking the switch on the lights. “So what did you make of that?” “Could you make any sense of it?” “Did you gain an impression of what this boy was feeling?” “Would you like to speculate on what each bit of the action in our session meant?” And when we fumbled for words and stumbled through some half-baked responses, she very gently began to describe what she thought had been happening.
The background situation, of course, was something I would come to find quite common. The boy was the older of two siblings who had begun to hurt his younger brother. The parents were at war, and our boy had seen repeated severe violence in the home culminating in a head injury necessitating hospitalisation for the mother. The boy had been bullied, and had threatened in a 6-year-old way to kill his father. This had prompted referral.
Our doctor matched each element of the session to a piece of the history. In addition, she began to describe the emerging relationship between her and the boy, his initial fears, his need for her to respond to threat in a non-violent way, his testing of the emerging bond. She made complete sense of the session mirroring the outside world, talked about something called ‘transference’ (as if we had been taught all about it), and discussed the beginning approach to healing through helping the child to make sense of the world of sand play as a bridge to making sense of the outside world. She described possible interventions she might make over the next few sessions.
I was gob-smacked. How could you get so much out playing in a sand pit? How did begin to learn about working with children and what to do but also what not to do, as well as pacing the planned therapy? I thought of not much else for days. I discussed the session and my responses with one of the consultants back at King’s, Gordon Stuart Prince. He smiled benignly, quietly suggesting that not only did I have some medical exams to complete, but then, even if I got into psychiatry, I might have to learn to walk before I could run. He was right. In fact, for many reasons, it was to take me 5 years before I became serious about child psychiatry as a career, and then a further 5 years before I could ‘run’.
I believe the ‘lady in the room’, was Eva Frommer, at the time a consultant child psychiatrist at St. Thomas’s Hospital in London, and author of Clinical Child Psychiatry (Heinemann, 1972). Our paths never crossed again, yet I have never forgotten her influence in my life.