piccies from clinic

...off to a great start - forgot my camera, so my phone (with a <1 megapixel camera) had to stand in. The clinic resembled a small military outpost, with heavy-duty metal grilles over all the windows (as seen in first picture). I manoeuvred my bike round the back, avoiding a hoard of hoodies hanging around the entrance. Middle picture: clock - a free gift from a drug company (nice retro design though) Right: a fan. commonplace in London these days, thanks to the recent heatwave. to the left of the fan is a trolley with the BCG kit on top.

pictures

Have resolved to take one picture of Hackney (or Whitechapel) every day (until I tire of it). Meanwhile, here are more selected holiday snaps. (All taken with Sony DSC-W1 and not manipulated)

'Humani nihil a me alienum puto'

(the motto of The Royal London Hospital. roughly translates as 'nothing human is alien to me' or to remove the double negative - all human troubles are my concern)

09:30
As I lock my bike to what looks like a secure railing outside the health centre, an elderly black man pops his head out of a window 2 floors up. "I wouldn't park there," he says, kindly, "last week someone cut my bike from that fence." I thank him for his advice. But 5 minutes later, I am back in the carpark as the receptionists won't let me keep my bike inside. I lock it right opposite the main entrance in a parking space marked "doctors only". Well, it doesn't say cars only! The road leading to the health centre seems to feature a different "serious assault - can you help?" (or "murder - can you help?") sign every time I cycle past. Minutes later, I am in the thick of Enuresis clinic (i.e. bedwetting 8-year olds); babies are thrust at me while mothers help the 'problem' child undress. Each child needs a full history and examination, urine test (plus sample to the microbioogy lab), and then lots of explanation - mothers are advised not to get cross, and star charts are given out. I've seen this all before as a medical student in Edinburgh, but in Hackney it is not quite the same. A family history reveals that father was tortured in his home country; it transpires that the child sleeps in the parents' bed, along with its younger brother. Mother speaks only Polish, or Albanian. The interpreter is a jumpy young man, who repeats all Dr. D's calm assurances at twice the speed and treble the volume.

11:00
On my bike to cycle to the Child Development Centre (CDC) to observe a Child Protection medical. Most of the referrals are for alleged physical abuse. Even though I have technically lived in Hackney now for 9 months, before this job I had never actually seen any of these clinics - they are all tucked away in the hearts of the many council estates. The CDC (which I expected to be a good-sized multistorey building as all children in the borough with disability are known to the services based there) turned out to be a small brown-brick shack (ok so it has 3 floors, but it is so small that one of the toilets had to be converted to make a treatment room) with an overgrown, locked garden that serves as an open-air storage area for disused furniture, toys, and the doctors' bicycles. I can't really write about the Medical here as it is confidential, but suffice to say it was pretty harrowing.

13:30
Back to 'base camp' for Child Health Clinic. I think I gave about 6 BCG shots (after explanation and examination). All the babies blurred into one after a while. The babies were all happy, bouncy little things, but the moms had various problems ranging from HIV to housing benefits. Some had already fallen out with and separated from their (6 week old) babies' fathers.

17:00
Home time. Community paediatricians certainly work short days, but they are tiring in their own way.

..not to mention

...as an extension from yesterday's post: have not played the piano since I left home to go to med school in 1998. Used to paint and write poetry but have not had time/energy since starting work. Used to read a lot, keep up varied interests, but all this has vanished from my life. Also, because work involves meeting lots of people, my desire for 'alone time' is greater than the urge to go out when I have a day off, with detrimental effects on social life. Working weekends means you can't build new friendships outside of work - e.g. you meet someone one weekend, then you have to work the next two weekends in a row, plus on-calls in between. 21 days later, they have forgotten who you are, and its back to square one.

Post-Weekend Crump

Sank into the sofa after work today (got off at 5) and promptly fell asleep for 1 and a half hours. I have been working every single day since the 24th of July, and did 3 thirteen hour shifts covering paediatric surgery last weekend. What happens when you have to work lots of long days in a row is that your body goes into overdrive mode - you lose the desire to eat, wake up early automatically and feel almost euphoric with exhaustion at the end of each shift. Then, when you get a day off, or a less demanding/shorter day, your body switches back to normal mode, and realises how tired it is. Suddenly, your legs feel so heavy you can't even stand up. (much less do the large, stinking pile of laundry accumulated from working 2 weekends in a row, or get any groceries). I did eventually manage the laundry after my (unplanned) nap, but I think the psychological effects of working so many days in a row are ongoing - when I sleep my mind keeps replaying scenes from work, and I keep waking in the night. The problem is, though utterly exhausted, I am not ill enough to justify taking a day off sick.

what price career success?

My favourite section of the BMJ is the obituaries. At the end of a long week, just at the point where I start to wonder if it is all worth it (having to work weekends for the rest of my life, endless postgraduate exams, the burden of other people's problems etc), the obituaries remind me that it is sometimes possible to achieve great things over a lifetime in medicine. The latest issue of the BMJ contains the obituary of Baroness June Lloyd (this is the obituary as it appears in the Times, as you need a subscription for the online BMJ). If you read it, you will discover that not only was she made a life peer, her image is part of the coat of arms (above) of the Royal College of Paediatrics and Child Health, which she helped found. She seems, on all accounts, to have been an extraordinary woman, almost the kind of person I would look to as a role model for my own career. (I am unlikely to become a Baroness of course, but one has to aim high if one is to achieve anything!) However, I say almost, because of this line: "She did not marry, and is survived by her brother." Last birthday, I was the same age as my mom was when she had me and I can't help but wonder if something has to give at some point. At present my (potential) family life is at a complete standstill while my job takes up close to 100% of my time and energy, and I try to ignore the fact that fertility decreases and the probability of genetic defect increases with maternal age. Would Baroness Lloyd have achieved all that she did if she'd had her own children to look after? Will I be forced to choose between career and family?

whitechapel to nuttall street 2.9km

I've cycled more than 60km in a day before, but the short distance between whitechapel and nuttall street seems to separate two different worlds. On the one hand, what is now familiar to me: the world of hospital medicine - the tyranny of the Bleep, pyjama-ed (or intubated, ventilated) in-patients to be reviewed daily, the weekly clinic list - booked up 2 months in advance. And on the other: community medicine - doctors without prescription pads who work from 9 to 4, health visitors who rule the roost, walk-in clinic patients who turn up either in droves or not at all - and have nothing wrong with them - apart from poverty and unemployment.

On the afternoon of my first day (yesterday), having been given a quick (and uninformative!) introduction, I was told to make my own way to one of the local clinics. It is located on the side of Hackney I usually avoid (see previous post); certainly more Hackney Gazette than N16. The low brick building is run down both inside and out, the windows have rusty metal grilles over them and all the furniture and clinic equipment looks circa 1970. There is a plastic doll (of the horror film variety, but in miniature) on the desk in the clinic room - she is naked and black, and sits next to a tray of orange needles and vials of BCG vaccine.

The first patient is a lovely 6-week old. She is growing well, doing all the things appropriate for her age, and her mother is quite happy with her progress. Dr. J explains and then administers the BCG vaccine. It all seems quite straightforward. The second and third patients are similar. Piece of cake, I think to myself, and then start fretting that I shall be bored of this job by the middle of next week. The next patient is a 7 month old boy who had attended the local hospital with infected eczema a week before, and now had cervical lymph nodes visible from across the room. He is hot and sweaty, but otherwise seems quite content, smiling and babbling at everyone. Dr. J umms and ahhs for ages before finally deciding to send them back to the hospital. I could've done that in about 2 minutes, but as I was only observing, I didn't comment. A 6 month old is brought in whose mother is worried he is not gaining weight. Mother is visibly depressed - she speaks in a soft, low voice, and avoids all eye contact. The (apparently omniscient) health visitor has discovered that the child's father has been seeing another woman - because the second lady has a baby of a similar age, and it is also his. On examinination, there is nothing wrong with the child. In fact, he is manifestly happy and healthy. I wait to see what Dr. J says to the mother. She reassures her that the child is well, but does not attempt to explore the other (arguably the root) problems. I suppose that is a reasonable response - one cannot expect to solve all of everyone else's problems. But at the same time, I was more than a little disappointed. On the one hand, Dr. J did not have the means to treat and follow up a clearly medical problem (likely infected eczema with lymphadenopathy); on the other, she chose not to delve into psychosocial issues which might have an impact on the child in the future. It was not a busy clinic, and my gut feeling was that the mother was simply looking for someone to confide in, even if they did not physically intervene.

I suppose the problem is that the patients (parents) think a community paediatrician is like a GP, but for children. The fact that the clinic is in a local GP surgery only serves to confuse things further. But the remit of a community paediatrician is quite different. There's all the public health stuff (child health surveillance, immunisation) and the legal stuff (child protection) and the ringing round and fixing patients up with the right services (psychologists, special needs coordinators, physios etc etc). All this I know in theory. But the reality of it is much more mixed up than I thought.