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.