Dissection, p.1
Dissection, page 1
About the Book
Dr Anna McBride’s life is starting to unravel. The mother of two boys and a dedicated GP, she is being sued for medical negligence—a case of delayed diagnosis. Deeply ashamed of her mistake, she doubts her abilities at work and retreats into family life, only to find that her husband seems preoccupied with a younger colleague. As the date for mediation draws closer and the lawyers’ demands become ever more pressing, Anna also senses someone else’s cries for attention—someone who wishes her harm.
First published in 2008 to critical acclaim, Dissection remains as relevant as ever. This absorbing novel reveals the uncompromising world of the medical profession, and the psychological toll it inflicts on one woman.
Contents
Cover Page
About the Book
Title Page
Dedication
Epigraph
February 18
February 20
February 21
February 25
February 26
March 2
March 3
March 4
March 5
March 6
March 8
March 14
March 22
April 2
April 11
April 14
April 16
April 21
April 25
April 28
April 29
May 2
May 5
May 7
May 11
May 12
May 13
May 14
May 15
May 20
May 22
May 23
May 25
May 26
May 27
May 28
May 29
May 30
June 3
December 5
About the Author
Copyright Page
For Michael
With my burned hand I write about the nature of fire.
INGEBORG BACHMANN (AFTER GUSTAVE FLAUBERT)
February 18
Doctor Anna McBride has begun to think of herself first. She has recently developed the habit, if that is what it is, of analysing her own reaction to a patient’s story, her feelings about the patient, before anything else. Thinking of herself does not make her feel better: on the contrary, it exhausts and irritates her. But if, in any given situation, she thinks about what is best for her, what is the safest course of action for her to take, at least, then, she is limiting her exposure. Isn’t that what the lawyers would say?
It has become an effort to get to work every day. She has taken to entering through the back door, so as to avoid walking through the waiting room. In the first few months after the writ was served, she continued to use the front door, although, like the physiological conditioning of Pavlov’s dog, just the sight of the clinic entrance — the paved stone steps, swept clean of leaves, the small garden bed planted with pink and white petunias — was enough to send her heart pounding. She would be breathless after climbing those four steps and the effort required to push open the heavy wooden door would sometimes cause her to cry with fatigue, as would the realisation that she was not as strong as she had once believed herself to be. She had decided, some months ago, she could not continue entering the surgery like that: tearful and breathless, like some sort of histrionic patient, rushing through the waiting room with her head down, holding back her tears. Such a poor way to start the day. She had initially been ashamed of this decision, seeing it as an acknowledgement of defeat, a backing away from her original stance that everything — her medical practice, her attitude to her work, her life at home — would remain untouched by a negligence claim.
In those first few days, as the writ lay, its manila folder still unopened, in the bottom drawer of her desk, she promised herself that everything would proceed as usual. Why should things change? She had simply made a small error of clinical judgement; an error that, if circumstances had been slightly different, would have amounted to a delay in diagnosis of a week or two. Would have, in essence, all amounted to nothing had the boy, Ben Feltham, attended his follow-up appointment, or had she ordered an X-ray at his subsequent visit. To therefore abandon the front entrance — the bulbous brass doorknob, the white plastic plaque on the adjacent brick wall, bearing her name and qualifications (MBBS, FRACGP, DRANZCOG: the acronym proof of her worth) in plain black lettering — might be seen as an admission of many things, as yet unsaid (but that might be said at some time in the future in a courtroom of the County Court); an admission of more than she was prepared, as yet, to yield. But on that first morning, as she unlocked the back gate, climbed the gentle incline of the wheelchair ramp and opened the back door on to a dim and silent corridor, she realised she had already yielded more than was good for her.
Today, on this third Monday in February, she enters the clinic by the back door and, as usual, goes directly to the bathroom to wash her face. In the bathroom mirror, under the dim overhead light, she studies her reflection. What she sees displeases her. Just three years ago, in her fortieth year, she could look in the mirror with, well, not exactly pleasure — there was always room for improvement — but with equanimity at least. The sight of her reflection at forty did not unsettle her, as it does now. The last three years have not been kind. It is not the crow’s feet around her eyes, nor the two horizontal creases now permanently etched across her forehead that particularly bother her. Specifics are not her concern. Rather it is the general drawing down of her face, the vertical displacement and slackening of her features, so that now, when seeing herself in a recent photograph, she finds the face that looks back at her both familiar and strange, as if she were studying an old photograph of her mother, or even her grandmother, rediscovered after being hidden for years in some dusty corner of the house. But she does not stand here each morning just to bear witness to her ageing skin. Instead, this bathroom ritual — the washing, drying and scrutinising of her face, reddened from the cold water and the rough cotton weave of the towel — is a therapeutic act, a necessary act of composure before the day’s work begins. She no longer knows how she manages it: this piecing together of facial features as she simultaneously pieces together her thoughts, the disparate parts of herself, so that, as she leaves the bathroom and proceeds down the corridor, her fingers trailing the cold brick wall, she presents as the picture of coherence and restraint. How does she manage it? She need not know. Perhaps, like a magician’s trick, it is better left unexamined.
The waiting room is almost full. Monday mornings are always busy with the accumulated problems of the weekend. It is, by anyone’s standards, a pleasant room to be waiting in: sun-filled and, now, newly carpeted and painted; her share of the refurbishment bill, paid just last week, amounted to one-third of her earnings for the month. A floor-to-ceiling window looks out onto the petunia bed and, beyond that, a slatted timber fence hides the noise and distraction of the street. The children’s toys are of an educational kind: wooden puzzles, dominoes in a rectangular box with a smoothly sliding lid, a metal construction set. A selection of recent magazines — Vogue Living, National Geographic— are neatly arranged on the large, wooden coffee table. During her training she worked in places with awful waiting rooms, cramped and dingy, strewn with dog-eared magazines and grimy, broken toys; rooms that simply did not measure up. When she first came to work in this practice, eleven years ago, she liked this room immediately. She still appreciates its good proportions; the northern light through the large windows that gives a feel of austere comfort, a restrained yet calming aesthetic, exactly what a doctor’s waiting room should project. It makes a good impression, this room. She has always believed in the value of making a good impression.
Behind the reception desk Margaret is on the phone, dealing with the Monday rush. They make eye contact, exchange knowing nods. She picks up the first patient’s file from her tray. The name is not familiar but when she calls it — Lisa Salvatore — she vaguely recognises the young woman who puts aside a magazine and rises from her seat to follow her down the corridor to her consulting room. At the door to her room she waits, gesturing with her hand and a small inclination of her head, for her patient to enter. Such well-worn habits: her upturned hand, her small tight smile as she makes eye contact with the young woman — her name is Lisa, she must remember it when addressing her — who smiles briefly in return. The stiff familiarity of the vaguely recognised patient, neither old patient nor new. Old patients, loyal to the grave, are prepared to forgive their doctor anything. New patients have no preconceptions. Lisa settles herself in the chair, her handbag on her lap. She looks in the file for the date of Lisa’s last consultation. It was eighteen months ago. Has Lisa been well over the past eighteen months, or, more likely, has she been doing the rounds?
Lisa has come for a repeat pill prescription. The same one she was taking when last seen at this clinic? No, it was changed by another doctor at another clinic, some eleven months ago. Ah! It is just as she suspected. And will that be all? No: Lisa feels as if her neck might be swollen. Her mother has commented on it. Lisa puts her hands to her thyroid gland. From across the desk, the young woman’s thyroid looks a little enlarged, but, then, she does not know how it looked before. In answer to her questions, Lisa tells her there is no pain or difficulty swallowing. There are no constitutional symptoms, apart from occasional tiredness, which can almost always be discounted. Everyone is tired these days. And yet tiredness can be a symptom of significant disease: leukaemia, diabetes, renal failure , depression. Nothing can ever be fully discounted. She stands behind Lisa, who still clutches her handbag — if body language is any guide, this reticence to discard her bag is not a good sign — and palpates the thyroid from behind, as she was taught to do as a student. Those distant days of medical school, when examining patients was a novelty and nothing more, a harmless routine to be rehearsed in one’s own time, at one’s own pace — though now she pities those frail old women, captive in unforgiving hospital beds, on whose arthritic hips or failing hearts she clumsily practised her craft. These days a physical examination carries with it the weight of diagnosis, of getting it right. She is no longer sure she can get it right, at least not every time.
‘We will do a blood test to check your thyroid function and an ultrasound of your neck to get a clearer picture of what is going on,’ she says to Lisa. She is conscious of using ‘we’ instead of ‘I’. Is she hiding behind fictitious others, trying to protect herself from being singled out for criticism? If so, it will not work. ‘And a couple of other blood tests to check your tiredness.’ Hang the expense, she thinks. Isn’t this what patients want: a thorough going-over? No room for uncertainty. No stone left unturned. She stands and sees Lisa to the door, then returns to her desk to write a few notes.
Before this all happened, before the writ was served, before the lawyers had her phone numbers — at a time when it now seems that all decisions fell lightly and easily into place — every consultation was simply an analysis of the patient’s problem. She would think in terms of the patient’s agenda, of what it was the patient wanted from the fifteen-minute interaction. Whether she would be able to provide the patient with what they wanted was another matter, but at least they would both know where they stood. During the consultation she would construct hypotheses, not only about the diagnosis of the presenting problem but also the patient’s real reasons for coming, the patient’s hidden concerns. She would use her communication skills, her medical knowledge, a certain level of intuition to tap into the patient’s health belief system; she would read body language, interpret the Freudian slip of the tongue, the use of key words. She projected outwards, towards her patient; in counselling parlance, she empathised. In her own modest way she could read minds. Now, as her patients talk, she turns inward, analysing her risk of exposure. She has spent so long with lawyers she is beginning to think in their terms.
February 20
Her last patient of the day is a forty-nine-year-old woman called Susan, new to the clinic. Susan explains how she is struggling with symptoms of the menopause. ‘I am so tired,’ Susan tells her. ‘Tired through to my bones. And still I can’t sleep. I barely get four hours a night.’ Susan’s voice trails away and she begins to cry.
She places the tissue box within Susan’s reach and waits while she wipes her eyes. She sees the consultation path stretching out before her: the exploration of Susan’s tiredness will lead to questions about lifestyle, work and family. Her husband’s attitudes and behaviours will be ever so gently probed. She will ask about Pap smears and breast checks, and encourage Susan in healthy habits. Take time out for yourself, she will say. They will circle the topic of hormone therapy: she will be cautious not to advocate it, even though she suspects this is why Susan has come. Even so, she will not prescribe it today, not without first sending Susan away, replete with handouts, to decide for herself. Hormone replacement has lately become a minefield of risks, a quagmire of qualifications. Doctors must tread carefully, and no one more carefully than she.
She can do all this, the peri-menopausal consultation, with her eyes closed. At this moment that is exactly what she would like to do: close her eyes and her ears, too, and rest her head upon the desk. She, also, is tired to her bones but, unlike Susan, she cannot find the time or see the need to burden someone else with her woes.
Before she leaves work she runs through the appointment diary on the computer, as is now her daily habit. She adds up the patients who, at review, have responded to her treatment, plus those who felt better by the time they left her room. The sum is disappointingly small. With a sinking heart she also tallies the patients whose cough has got worse, whose rash has spread, despite her interventions. Would they have been better off if I had done nothing? she asks herself each evening as she walks to her car. Would they have been better off seeing someone else?
Before Ben Feltham she had believed, had she ever stopped to consider it, that on the whole the medical profession did good: lives saved, diseases prevented and cured, suffering ameliorated. How could she have continued in her profession if she had believed otherwise? Of course there were times, isolated events, when the harm done by a doctor outweighed the good. In her days as a resident there were the occasional catastrophes, procedural mishaps: the misplacement of a central venous line, for example; the cannula failing to enter the internal jugular vein, instead puncturing the apex of the lung and causing it to collapse with a soft hiss like a leaking balloon. And, infrequently, misdiagnoses that led to permanent disability, or even death.
She often thinks now of one particular woman, a patient in her care during the first few months of her intern year. She does not remember her name, that unassuming woman who came alone to the hospital one evening with bad left-sided subcostal pain. She had not been present when the woman arrived but she later heard the story from the intern who had first seen the woman in emergency. The woman told the intern she had been the driver in a car accident, several days before. Just a minor one, the woman said: no injuries sustained, save for a little bruising. This was duly recorded in the emergency-room notes; recorded then forgotten. After the physical examination the intern ordered, amongst other tests, a chest X-ray. The films came back with some changes in the lower lobe of the left lung, the same site as the woman’s pain. Could she have pneumonia? No one in emergency was quite sure and, being after-hours, the radiologist was not there to report on the films. The woman had no cough or fever: what then to make of it?
The medical registrar was called down from the wards for his opinion. ‘Does it hurt when you breathe in?’ he had asked the woman. The doctors in emergency had not asked this question; had not thought to ask it. ‘Yes,’ she replied. He took her pulse and noted it was fast. Pleuritic chest pain, tachycardia, the registrar wrote in the emergency notes. Diagnosis: pulmonary embolism was written below. A blood clot in the lung. The patient would go to the medical ward for anti-coagulation.
At that moment, when the registrar announced his diagnosis to the emergency-room staff and the admitting officer picked up the phone to find a bed on the medical ward, the woman’s pain, until then undifferentiated, now had a label. Her constellation of signs and symptoms, and the finding on her chest X-ray — that hazy lung opacity that, in retrospect, could have meant many different things — were gathered together under one diagnosis and labelled as ‘medical’. The woman was deemed to have a medical problem, rather than a surgical one. These days, as a generalist, as one who claims to treat the whole patient, she sees this rigid separation of the medical from the surgical as a dangerous practice, though one common in resident doctors, at least of her time. Is it any different now? Do hospital doctors take a more holistic approach, or do they, as she once did, still label and separate — the liver from the lungs, the head from the heart, the body from the mind? She knows nothing of teaching hospitals now, except what her patients tell her: dirty bathrooms, harried nurses. In her day the bathrooms were clean and nurses thick on the ground. Have the hospital doctors changed, too? She suspects very little, if at all.
In the medical ward, two days later, the woman was still in pain. Her lung scan had been equivocal but still the heparin ran, drop by drop, into her bloodstream. She still remembers, or at least thinks she remembers, the expression on the woman’s face during the ward round that morning. An expression of fear: fear of suffering, perhaps, or else an intuitive fear that the diagnosis of pulmonary embolism was incorrect. When later that day the woman’s condition deteriorated — her blood pressure and haemoglobin fell, indicating internal bleeding — and a surgical opinion was urgently sought, it was decided the woman was suffering, not with a pulmonary embolism, but from a surgical problem: that of a ruptured spleen, no doubt sustained in the car accident, during impact, as the seat belt pressed into her abdomen. She was rushed to theatre for an emergency laparotomy and there, as the surgeon had predicted, was found to have a ruptured spleen; the bleeding, increased by the anti-coagulation therapy, still contained within the fibrous confines of the splenic capsule. Her spleen was removed, she was transfused and, by the skin of her teeth, she survived.
