Mea culpa: Looking back on a life of medicine

“Learn from the mistakes of others. You can’t live long enough to make them all yourself.”

— Eleanor Roosevelt

At the end of my second year at Auckland Medical School, my girlfriend and I found ourselves pregnant. You could make a case for including contraception earlier in the curriculum, but it was our mistake.

We both came from caring, conservative Christian families, who we had no intention of upsetting, but of course they took it hard. However, we were naively delighted and hastily planned a budget wedding, which took place in the university chapel at 5pm on a Friday. This was 1972. To not marry would compound the offence. We did it our way, arriving together in matching maroon-and-white outfits and walking into the chapel holding hands. The words of commitment were chosen by us, and it was heaps of fun.

Our families were shell-shocked initially, but after lobbing a couple of small grenades at us, they emerged from their trenches to be very supportive and accepting.

I managed to scrape through my third year with a pass and a delightful baby daughter, Nicola. Marion completed her graduate teacher training that year too. It was tough going, and we were very poor those first few years, living frugally and sharing expenses in a large student flat.

My first house-officer job was in Whangārei. Our son, Simon, was born that year, and as Marion laboured through the day, I felt it was my duty to keep attending to ward work and pop down to delivery every hour or so to check in and offer a few minutes of support. Due to some misguided sense of loyalty, I didn’t feel I could ask my colleagues to cover my work, while I was merely support­ing my wife in labour.

It is hard to think of a worse example of “presenteeism” – of being present in the workplace when one ought to be absent. Thankfully, I was there for the delivery in the middle of the afternoon. I can’t remember now whether I went back to the ward afterwards to tidy up outstanding tasks. My guess is that I did.

The following year, I took a year off work to be a father and husband at home. This enabled Marion to teach for the first time since completing her teaching diploma. We lived that year in a school flat next to Mahurangi College in Warkworth. She had a great year teaching, and I enjoyed the break from medicine doing housework, growing vegetables, studying philosophy from Massey University and spending a lot of time with my young children.

Then back to Auckland to continue my medical career. Many years later, Marion told me this was never properly discussed, just assumed by me that I had done my heroic domestic duty for a year and that normal service would resume thereafter.

She would have liked to teach for another year, but I never gave that a thought. I wonder if it was the arrogance of assuming my career was more important, or sexism?

I feel ashamed now, but at the time I just blended in with the way things were being done

After a year of paediatrics, I embarked on my diploma in obstetrics at National Women’s Hospital, and I was there during the Professor Des Bonham and Professor Herbert Green years, prior to the Cartwright Inquiry. Then, it was assumed that if women wanted first-rate care in a public hospital, they should be happy to participate in research and teaching. In that context, I was taught how to insert and then remove IUCDs on anaesthetised women prior to a hysterectomy. They were never asked to consent to this taking place.

I feel ashamed now, but at the time I just blended in with the way things were being done, and I didn’t think to question it. There appeared to be no victim, and I learned a valuable skill.

Similarly, when I was a fifth-year student, I was in a small group on a medical ward having a tutorial with Professor John Scott, for whom I had a lot of respect. Professor Scott asked if we had all performed a rectal exam. I hadn’t. He asked me to come with him and told the others we would be back in two minutes. He took me to the nearest four-bed men’s room, picked up some gloves and lubricant from the nurses’ station as we passed, and drew a curtain around a patient saying, “I’m Dr Scott and this is Dr Judkins. We need to check on something if you don’t mind. Please lie on your side facing the wall and lower your pyjama pants, bend your knees up …” He performed a brisk PR exam, gestured to me to copy him, thanked the patient, and we returned to the other students and continued with our tutorial.

Marion and I wanted to experience living and working in a poor country before settling down to the ties of home ownership and general practice. We were accepted for a two-and-a-half-year stint with the United Mission to Nepal, to commence January 1980. That gave us six months from the completion of my obstetrics diploma, to do a grand OE tour of the UK and Europe on the way.

We sold the car, withdrew our savings and flew to London. On the flight out of Auckland, Marion first suspected she was pregnant. Three-year-old Simon became itchy on the plane and we discovered chickenpox vesicles, which we did our best to ignore, although he would have been highly infectious. After a visit to Disneyland on the way, shedding varicella virus every­where we went, we arrived in London. We promptly bought a VW Kombi campervan, a map book and an AA guide to the UK, and hit the road.

A Kombi is very compact and is not self-contained, so finding public toilets and a place to park on demand with two children in the back (no seat belts), soon took priority over everything else. We bought a simple free-standing chemical toilet, which we named George. George saved our lives as he accompanied us on our travels around the UK and then Europe.

We made the mistake of insisting that Nicola, who turned seven in Germany, keep up with New Zealand correspondence schooling by spending weekday mornings working in that tiny campervan, rather than relaxing and exploring and appreciating that education is more than school lessons.

And another – trying to visit every country in Europe, and being constantly on the move from one campsite to the next, rather than consolidating impressions of fewer places. One branded memory is of arriving in Naples at rush hour, driving through swarms of Fiats and Vespas, trying to navigate our way to the chosen camping ground from a map book.

We arrived back in London at the start of November, precariously poor, living in an uninsulated tin box when the nights were very cold. It was two months until we were due to depart for Nepal. I had to find a job. That meant going into the British Medical Association offices in Tavistock Square, buying a copy of the latest BMJ, turning to the job vacancies and taking it to a phone box, dialling numbers and inserting coins. Battle Hospital in Reading, Berkshire, urgently needed a senior house officer, and they provided accommodation on site. The relief was enormous as we headed west on the M4 motorway to a short-term job and the luxury of a warm flat.

We communicated with family back in New Zealand by weekly postcards or aerogrammes. International phone calls were prohibitively expensive. It was also time to get some antenatal care, as Marion was now at the end of the second trimester. Oops! I can’t believe we were so casual about antenatal care, especially so soon after I had completed my Dip Obst.

I later realised that by applying my egalitarian Kiwi principles, I must have humiliated this official

The missionary organisation we were to work for had booked us to fly in January on the cheapest flight from London to New Delhi – with Ariana Afghan Airlines. In December 1979, television news showed invading Russian tanks circling Kabul airport, where we were to stop for refuelling. Our travel was changed to the next cheapest – Iraqi Airlines, refuelling in Baghdad. I sold the Combi van, we packed all our possessions into two backpacks and two suitcases, and took the Underground train to Heathrow Airport.

Iraqi Airlines didn’t allocate seat numbers, just a boarding pass like a bus ticket. There was no in-flight service. A turbaned man in the row behind us kindly introduced himself as an obstetrician, in case we should need him. Marion must have been 34 weeks’ gestation at the time. We thanked him for his offer and didn’t disclose that I was also a doctor. We had become used to keeping our fingers crossed.

We settled into four months of Nepali language study in Kathmandu, and a few weeks later Rachel was born there. With a track record of only one planned child out of three, and the only available contraception being condoms, I immediately decided our family was more than adequate and that I ought to have a vasectomy.

I arranged to have this done as soon as possible in Kathmandu. Marion didn’t argue at the time because I was so determined this was the right thing to do, but she later said she wished I had discussed this with her, as she would have preferred to keep our options open for longer.

We were assigned to a 100-bed mission hospital in Tansen, in the western hills of Nepal, a 10-hour journey from Kathmandu on overloaded buses on winding broken roads. I soon found myself having to deal with a wide range of presentations and conditions that I had no prior experience of.

I remember feeling overwhelmed when a man was brought in one evening, unconscious and having difficulty breathing. I was told he had been bitten by a krait (venomous snake), and the hospital had no anti-venom. While I was dithering, realising the situation was hopeless, the Nepali nursing supervisor who happened to be hovering, advised, “You have to do something, Doctor. Put up an IV line or give him some injection. It is better for the man to die while the foreign doctor is trying to save him, than for him to die while the foreign doctor does nothing.”

I was slow to adjust to a different culture. Patients arrived at the outpatients’ clinic in the morning, paid their two rupees registration fee, and were given a numbered ticket indicating the order of arrival. They then waited for hours but would be seen sometime that day. A well-dressed government official approached me as I walked through the crowded waiting area, and he asked in English if I would see his relative who was waiting. I looked at the ticket number and asked them to wait, saying when their turn came, I would give the best care I could. I later realised that by applying my egalitarian Kiwi principles, I must have humiliated this official. I was still adapting to a society where it was expected that important people and their families would be given priority.

In the middle of our last year in Nepal, I had to plan for our return to New Zealand, and I applied by letter for the GP training scheme in Auckland. A remote interview was impossible in 1982, and at that time there were only 50 first-year GP registrar positions in the country, 12 in Auckland. I received a reply saying I had had more postgraduate experience than most, and that rather than offer me a training position, they suggested I just find a GP job and attend Goodfellow courses and conferences. So that’s what I did, eventually sitting the exams and gaining Fellowship without any training. A few years later, I became a GPEP teacher, but I was never taught as a registrar myself.

I believe I have been a careful and conscientious doctor over 39 years in general practice, but there have been slips. In 1998, I was summoned to appear in the Auckland District Court as the second defendant, when a patient of mine sued an insurance company for declining to pay out a substantial sum for loss of earnings due to stress and depression. When he had applied for income protection insurance, he asked me to make no reference in my medical report to a previous significant episode of stress. He had not declared it in his personal statement and he was convinced it was fully in the past and that it could unfairly prejudice an insurance company against him in the future. Unwisely, I agreed to his request. He later had a major breakdown, didn’t work for six months, and made a claim which was declined once the insurer had accessed all his records. The patient was now seeking compensation from the insurer, and if unsuccessful, he sought it from me for having failed to advise him appropriately.

Fortunately, the judge ruled that the insurer must pay out, but he also stated that I had acted negligently, failing in my duty of care to the insurer, the party paying me to complete the report. He said in his ruling that I could learn a lesson from this case. I certainly did, and I share it so you can too.

Then in 2008 I received notice of a complaint to the health and disability commissioner. Perhaps we should all expect at least one of those to come our way, but I found the protracted process harrowing, even though the eventual findings were not too bad.

A 70-year-old patient of mine had presented two years earlier with mild urinary symptoms. I examined his prostate which was clinically benign, and requested a PSA test which was mildly elevated. I set a task for the nurses, requesting the patient have a repeat PSA in three months, to see if it was stable or rising. I should have phoned the patient to explain this result and the follow-up plan to him, but I failed to do so. Three months later, the nurses sent a laboratory form for a repeat PSA test to the patient, with a brief covering letter. The test was not done and we had no system in place at the time to alert us to outstand­ing tests. The patient presented again more than a year later with metastatic disease.

At the end of the HDC inquiry process, our lovely practice, which had just recently passed its second Cornerstone accreditation, was found to have been in breach of the patient code of rights. The patient could not be considered responsible for failing to get a test when requested, if the significance of the test had not been adequately explained to him. We promptly set up a system for tracking all laboratory and hospital referrals, to alert us to all those without a timely outcome.

As is so often the case with complaints against doctors, I had made a sound clinical decision to repeat the test after an interval, but I had failed to communicate this course of action to the patient.

My most embarrassing moment in general practice occurred on a postnatal visit to a patient and her baby in the birthing unit. I found the baby on the breast and feeding well, but with a long black hair protruding from a corner of the baby’s mouth. I reached over to gently pull it out, to discover that it was attached to the edge of the mother’s nipple.

Another embarrassing mistake is summed up in this little poem:

When are you due?

I asked She wasn’t

Rapport aborted

Early in my life as a GP I wrote an aspirational mission statement, adapted from a prayer, and had it written in beautiful calligraphy and framed. It has hung on the wall in front of my desk ever since.

God help me

to put myself in each patient’s shoes

to see the world through each patient’s eyes

and to treat each patient

as I would want to be treated myself

I still love those words, but at times I find the ideal elusive. However, I try not to fret about that too much, as I am learning to accept the limitations of being human – learning to have self-compassion when I have failed to live up to my own expectations, to try to learn from every mistake, and to enjoy the marvel of the journey.