Hugh Tunstall-Pedoe
Dundee, Scotland

It was my very first patient. I had started my clinical training at Guy’s Hospital medical school in 1961 in London by being put straight onto a surgical ward. The patient was a Bermondsey Cockney dock worker who had a benign tumour to be removed—a neurofibroma. I examined him and read it up. As I was clerking and examining a patient for the first time, I encountered momentary panic on taking his blood pressure, as my ear was not attuned to Korotkoff sounds—it took more than one attempt to get a reading. Later the senior registrar came round with the gaggle of us students, paused for my presentation, and moved on.

That evening, I was about to go home when I was hailed by my Cockney patient from across the ward where he was chewing the cud with other patients. “Doctah!” What? He cannot mean me, I have never been called that before! He called me again. “Doctah! You done okay! ‘Ee was very pleased wiv yer! I know ‘cos I was watchin’ ‘is face!” Indeed, he was. He had fixed my interrogator with an unwavering stare, and nodded his head vigorously to show agreement whenever I made a statement or answered any questions.

A new experience! I was pleased, but surprised to find that my patient was looking after me. I thought it was supposed to be the other way round. Ever since, I have been touched by my patients looking out for my welfare. Repeat outpatient attenders, paradoxically, often get their health enquiry in first “Hello, doctor, how are you?” It seems illogical. Yet it serves a social purpose. Besides expressing warmth and genuine concern, it challenges the one-sidedness of the doctor-patient relationship and gives it mutual respect. The questions and answers are conventional and must not be taken too literally. As in normal exchanges of greetings, it is better not to complain. On the other side, patients with chronic or fluctuating conditions may be reluctant to admit that all is not well, putting on a brave front (“musn’t grumble—could be worse”) on first being questioned. They need deeper probing with specific questions. In retrospect, I cannot remember this being discussed specifically in my training; I learnt by example and experience.

Inevitably, the ideal of mutual respect, trust, and affection between doctor and patient can be missing, broken, or put under stress, as I experienced in four decades of clinical work and as shown by the following few examples. (And of course, nowadays, the doctor-patient relationship is less frequently one-to-one).

• The new outpatient whose visit, demeanour, and body language, right from the start, told me he was hostile and would complain about me, as he inevitably did.
• The neurotic Northern Irish woman during the Ulster “Troubles” who suddenly started shouting that she was going to get her IRA friends to kill me. No prizes for guessing that the threat was never executed! Most patients visiting a hospital doctor are on their best behaviour—and many will have had a bath or a shower and changed into clean clothes specially. So this was an exceptional display of bad manners. Unfortunately, my longstanding, loyal clinic staff nurse was of Ulster Protestant origin, and it was too much for her to bear, poor girl—she should have left the conflict behind when working in London—and she burst into tears.
• The strange girl who lay on the cardiac clinic floor writhing and screaming—her bizarre reaction to a single cardiac ventricular ectopic beat.
• The woman I saw in medical outpatients as an inexperienced junior doctor after a night on emergency duty with virtually no sleep, who as she entered the clinic room, announced “Doctor, I feel awful all over!” She had a monumentally thick folder. She had been seen every three months for a decade or more by other junior doctors with no diagnosis made, some unhelpful tests ordered, and three-month follow-up appointments repeated ad nauseam. In my exhausted and helpless state, I became angry—this was the only time I can recollect losing control of my temper. I read out loud to her a litany of uncomplimentary comments made about her in the notes by my predecessors—any therapeutic intention was coincidental. Later, I simmered down. Upset and ashamed and almost in tears, I recounted the episode to my consultant who arranged to see her. He reported back to me later, that like me, he had found her very difficult indeed, but not what he had done. I was not to know that the syndrome would be written up years later in the 1980s as “heartsink,” unusually describing the patient’s effect on the doctor—rather than the patient him- or herself—as the main characteristic of the condition.
• At the other extreme, the woman who had unexplained blackouts, whose medical treatment I had changed, not being sure, with side effects, that it was appropriate, who shortly afterwards collapsed against a plate-glass door, smashing it. I wondered if I would ever see her again, having worried over the implications of my recent management, but she showed up at her subsequent appointment, to my relief, as warm, friendly, and trusting as ever.
• Called out to the intensive/coronary-care-unit at a postgraduate hospital decades ago, at two o’clock in the morning, my patient, in surprise, said to me, “Hello, doctor, what are you doing here, at this time of night?” I did not think I should tell him: that because a cardiac monitoring lead had fallen off him, the alarm had gone off and the inexperienced nurse on night duty had sent out a crash call as if he was in cardiac arrest and near to death—thankfully a false alarm and very evidently untrue! Recently roused from sleep and unsure what to say, I cut him off with a conversation-ending, non-committal response.