A Doctor's Journal
Bedside Manners
IWAS encouraged to read a report about how the surgeons of a Croydon group of hospitals, before an operation, sit by the patipt's bed and chat with him, leading up to a diplomatic explana- tion of why the operation is necessary. The secre- tary to the committee said, This bedside chat makes a patient feel that the surgeon is a personal friend, and that he can rely on him to carry out the operation with success.' Of course this very sensible procedure reassures the patient. 1 should think that in many hospitals this kind of thing, or something like it, is done as a routine, but now and again one still hears hair-raising tales of operations decided upon (by the surgeons) and carried out with scant explanation, or none at all. '
Of course, surgeons as a race are active and impatient people; they like to get on with things, and may be so brisk as to leave out the emotional preparation of the patient for what is, after all, a major event in his life. How very satisfying a successful operation must be! The appendix is inflamed, the patient is twisted up with pain, scared and in danger; the surgeon operates and takes it out, and all is well. The new surgery of the heart I would regard as one of the greatest advances in healing ever to be made. I hope we' can look forward to the day when many, or most, victims of valvular heart disease can be relieved of their crippling disability by operation. This is surgery at its best. But sometimes operations are done without so clear a purpose. For example, it is nearly always a mistake to operate on women with tension pain. The pain is not made better by surgery—in fact, it is usually worse, and the patient is left with the conviction, not unreason- - ably, that her pain must be of physical origin because Mr. Scalpel did an operation for it. Hence the task of the next doctor who tries to help her is made more difficult. It would be instructive to carry out a survey of all patients submitted to surgery, to find how many of them go on having symptoms after the operation.
Be a little more helpful, please, says a reader from Oxford. How does the heavy smoker give up smoking? How can he stop, and how neutra- lise the subsequent depression? How long does it take, he asks, to get the nicotine out of one's system? Well, giving up smoking has little or nothing to do with nicotine. Addiction to cigar- ettes—for the pipe seems to be pretty harmless.— like any other addiction is a form of stress response. However, unlike other, benign re- sponses, such as twitching of the head, it does damage to several of the bodily systems, and the more cigarettes are smoked the more damage is done. Furthermore, it seldom quite quells the discontent that keeps it going, and it brings with it practical complications, such as an increased liability to chest trouble.
I mentioned lately the vicious-circle effect in smoking; that each cigarette sets up the craving for another. This simple habit-smoking, as one might call it, is, I imagine, relatively easy to check. Break the circle for a few weeks—by an act of will, a tranquilliser, or hypnotic suggestion—and the craving dies down. But if the addiction has any real drive behind it, then it will have to be ex- plored, and there are lao magical remedies, and no
short-cuts to this. The exploring of it is part of a doctor's job, and it takes time and patience and privacy. During the stage of deprivation, the smoker must expect to suffer, as the morphine addict suffers when his morphine is withdrawn, but he can be helped and supported through this stage; he has to be on guard against taking refuge in 'nibbling'—sweets, biscuits, and the like : the smoker seems always impelled to turn to carbo- hydrate, rather than protein, during his weaning. The end-point is a rearrangement of forces within the individual so that his emotional needs are met. without depression or addiction; in some people, naturally, this point may be difficult to reach, or even impossible. The judgment on how to proceed in therapy, or whether to start at all, has to be made afresh for each person, after an appraisal of his attitudes and motives, and his situation in life. Sometimes it will be wise to let well enough alone.
I am sometimes very much troubled, when I reflect upon the three great professions of Divinity, Law and Physick; howthey are each of them over-burdened with practitioners, and tilled with multitudes of ingenious gentlemen that starve one another. (Spectator, March 24, 1711.)
The over-burdening, in the field of Physick in our time, is seen in the cities, and the country towns of Southern England; industrial towns, and the deep country, are less well provided for. The medical practice of the city is 'mechanised' to a high degree; the doctor who is so inclined can send any of his difficult cases to hospital, and the paradox is that he is often highly regarded by his patients for doing just this—'He is so careful,' they will say. The horse-and-buggy-doctor had a much harder time, and much keener delights.
MILES HOWARD
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