This piece is based on an assignment for a postgraduate paper on The Nature of Medical Practice. It has allowed me some reflection on my experience of medical practice at different stages of my life. It also gives some valuable background about the context for the other stories.
My Life as a Doctor
Life can only be understood backwards; but it must be lived forwards (1).
It is impossible to write about myself as a doctor without some description of me as a person, in the same way that I would now have difficulty describing a patient simply in terms of their medical condition. This account will therefore be based on a biographical account of my life, concentrating where possible on connections with my medical career.
I was born in Mataura, where my father worked in the local freezing works. Years later I attended a lecture by Professor Dennis Bonham, who had conducted New Zealand’s first perinatal mortality survey. He showed a slide of the maternity unit where I had been born, describing it based on its poor performance over the years as “the most dangerous place in New Zealand”.
When I was 10, my parents bought a small farm near Cromwell, and we moved to Central Otago. My childhood memories are of helping on the farm, playing in the hills, and occasional seaside holidays on the south coast. I remember three or four encounters with different doctors for various injuries and minor illnesses.
I was always a studious child. When I was seven, my parents bought me a set of children’s encyclopaedias, which I read cover to cover, often by torchlight underneath the bedclothes. A teacher suggested when I was about to finish primary school that I would get a “better education” at school in the city. My parents arranged for me to attend a school in Dunedin. I went on to Otago University with very little idea of what I hoped to become. One of the senior students at my hall convinced me that if I wanted to keep my options open it was a good idea to do Medicine. I applied for second year Medicine and was accepted. I often joke with family and friends that “I still don’t know what I want to do when I grow up”.
I did my best, it wasn’t much.
I couldn’t feel, so I learned to touch.
I’ve told the truth, I didn’t come to fool you (2).
Otago at that time was a deliberately traditional medical school. We were taught preclinical subjects with no explanation as to how exactly this information might be relevant to patient care. I suspected that the large proportion of my classmates who had parents who were doctors had something of an advantage. I found the topics interesting, but my marks were disappointing. In my clinical years, there was limited preparation for what were often uncomfortable encounters with other human beings. One especially embarrassing experience was attending the gynaecology clinic. Women attending as patients were required to change into gowns that barely covered their upper bodies, were strapped up into lithotomy position with the referral note by their left foot, and first met the gynaecologist, accompanied by up to six medical students, when he appeared from behind a curtain at the foot of the bed.
When I finished sixth year I decided to work as a house surgeon in Palmerston North. It turned out to be a good choice. It is the smallest city in New Zealand with a university. There were few registrars and no medical students so I got a lot of practical experience and direct contact with senior doctors. Now that I was looking after patients, I began to be influenced by the clinicians I was working with. One was Mason Durie, then a young psychiatrist, now a distinguished expert in Māori health, and a master of cross-cultural communication – Mason once won an award as a psychiatric resident in Montreal where patients voted him as “the doctor who best understands what I am saying”, though he claims not to be able to speak a word of French. More significantly, he taught me the importance of making a carefully considered diagnosis, even in a “woolly” discipline like psychiatry, before embarking on treatment. Another clinician who influenced me was John Coutts, a skilled surgeon, who taught me the real importance of knowing “the patient who has the disease” (3). He also had a strong sense of social justice. He occasionally agreed to help out his colleagues with more complex operations at the local private hospital – “little sisters of the rich” he called it – as long as they didn’t pay him.
I stayed on as a senior house officer for a six month run in obstetrics and gynaecology to complete my Diploma in Obstetrics. It was a valuable experience, as I was starting to figure out by then what the job entailed. I later returned to the Manawatu for what was then called the Family Medical Training Programme (FMTP). I was lucky during this year, after an extended period in hospital practice where primary medical care was viewed rather negatively, to work with GPs like Lindsay Quennell, Peter Broad and Jim Hefford, who understood the importance of the work they did.
In between, I travelled to England and worked for three years in hospital positions, fitting in 12 months or more off travelling. It was useful working in a different health system and gaining more practical experience in procedures. More importantly, I was able to advance my understanding of culture, history, art and language, all interests that had been relatively suppressed in small New Zealand towns, a boys’ boarding school, and probably especially at medical school.
Perhaps with this experience in mind, after my FMTP year I took up a volunteer position as a primary care and rural hospital doctor in Vanuatu (4). This was a life-changing experience in a number of ways: I had to learn to practise medicine with limited resources, relying more on basic clinical skills; I had to learn to manage in a completely different culture, in a country divided by language; and I met my wife, Joan, which has helped me in many ways, including the opportunity for an extended experience of my medical work in that setting.
One useful decision I made during my time in the islands was to begin extramural study in arts subjects through Massey. I started doing papers in literature and linguistics and French language, then switched to a major in education, in the hope that this would help my career prospects. I saw these papers as directly relevant to my work as a doctor. I found I was spending very little time with patients wondering what their molecules were doing, and much more time having conversations with them and trying to make sense of their lives. I also gained new insights into the education system and into learning and development. I found that new ways of thinking, which I believed I had discovered for myself, were already described, and had names.
Back in New Zealand, I worked as a solo GP and rural hospital doctor in Ranfurly. After our first child was born, I moved to a position in Kaeo in Northland, where the work was similar, except there I was salaried and was working with two other doctors. Also it was a predominantly Māori area, which was not all that unusual to me having grown up in Mataura, but gave me added insight into Māori culture and issues, especially as they related to health care. When our children started primary school, we moved to the city, for me to run the Auckland School of Medicine’s general practice in Manurewa and to teach in the General Practice Department. City life was not too bad. South Auckland especially is more of a collection of linked small communities than a large anonymous metropolis, and we benefited from a different range of available activities, and closer connection with Pacific people. Teaching at the School of Medicine helped me to formalise my knowledge of the basic tools of general practice, including communication skills, and gave me some opportunity to participate in research.
I always maintained an interest in rural practice (5). I decided to return with my family to live on a small farm in Central Otago, and work as a doctor at Dunstan Hospital. I wanted to live rurally, I wanted to work in a generalist scope and I wanted my work to be publicly funded. I had no particular interest in hospital practice; in fact Dunstan was the biggest hospital I had worked at for nearly 20 years, and I struggled initially with much of the clinical work. I was lucky to be working with a quality team of doctors and other health professionals, notably Garry Nixon, who has similar interests and values to me but is perhaps more comfortable working within a biomedical framework and has made a greater commitment to learning the details of disease management. I have also been fortunate having a part-time appointment to the Dunedin School of Medicine, which keeps me in touch with the learning needs of younger doctors.
O wad some Pow’r the giftie gie us
To see oursels as others see us! (6).
I don’t know what I am like as a doctor; that is for my colleagues and patients to judge. I do know what it is like for me. Medicine I admit remains largely an exercise for the mind, but with the satisfaction of knowing about patients and their lives, not just about their diseases and treatments. I am fascinated by the diversity of people I have encountered, by the connections between them, and by the way they tell their stories. I remain uncomfortable with the intimacy sometimes required, and with intrusive enquiry into various private bodily functions. I don’t like causing pain. I don’t like taking money off sick people.
I believe that the old-fashioned rural doctor, the kind I occasionally encountered as a child, and the kind I came closest to emulating in Ranfurly, is the classic generic doctor, and the one who has the most to pass on to students. I understand but am disappointed by the withdrawal of my colleagues from areas such as obstetrics, after hours and palliative care. I believe that the type of doctor I have become has been shaped by my medical and other life experiences, and I hope that the way the various bits of this have come to fit together has been clear from my description of significant life events.
(1) Kierkegaard Sjoren. Cited in http://quotations book.com/quote/23719/
(2) Cohen Leonard. 1984. Cited in www.azlyrics.com/lyrics/leonardcohen/hallelujah.html
(3) Osler William. The Principles and Practice of Medicine. 1892. Cited in http://www.thenewmedicine.org/timeline/doctor_patient_book
(4) Lloyd Trevor. Rural health in Vanuatu. New Zealand Family Physician. 1983; 10(4): 205-6.
(5) Lloyd Trevor. Reflections on three isolated rural practices. New Zealand Family Physician. 1996; 23(5): 43.
(6) Burns Robbie. 1786. Cited in. The Oxford Dictionary of Quotations. Third Edition. 1985. Oxford University Press. p.115.
– Trevor Lloyd
Trevor was born in rural Southland. He has been a GP and rural hospital doctor in Vanuatu, Central Otago and Northland, and now works at Dunstan Hospital in Clyde. He and his wife, Joan, have three children and live on a small farm near Bannockburn.