_______
One of my first clinical attachments as a third-year medical student was at St Andrew’s Hospital, in the East End of London. It was apparently built along architectural lines favoured by Florence Nightingale, and opened in 1873 as the Poplar and Stepney Sick Asylum. It became St Andrew’s in 1921, had a school of nursing and as with hospitals at the time, transferred into the National Health Service when it was formed in 1948. The hospital site was closed in the mid-1980s, but I remember it having one of the longest corridors leading to the accident and emergency department. It was a favoured fantasy of us juniors that the crash team (the team of doctors who would respond to an emergency bleep in case of a cardiac arrest) could get on roller skates at one end of the corridor, and skate down it to the patient at the other.
I don’t recall much about my attachment, or any of the patients I met there. But I remember the hospital, its large curved columns and its massive wards; of particular note to me were the scuff marks on the walls and pillars which had been made by passing gurneys. This was where I spent long periods in the library, reading and searching the literature for information on gliomas and other brain tumours.
My grandmother had been rushed into hospital in Hong Kong with an unremitting and extremely painful headache. The doctors and nurses had done all they could do, but without a brain scan they could not investigate any further. My parents were called in, and they immediately gave financial authorization for the CAT scan to go ahead. It concluded that my grandmother had a brain tumour, and the treatment recommended was surgery.
The anguish, worry and fear I felt was exacerbated by being so far away from home, and made worse by the information I had found myself reading in the medical library. Instead of being reassured, this overwhelming exposure to every possible complication and risk, however small, ate away inside me – and being so new to the world of clinical medicine, I found it almost impossible to make much sense of what I was reading. My tutor was completely unmoved by my predicament. He did not understand why I was so worried, nor why I needed to know as much as I could. I realised then that there was very little in the way of pastoral care, support and understanding from within the medical profession. You either survived or you didn’t.
When my grandmother refused to have surgery, the hospital discharged her, saying they needed the bed for someone else who wanted treatment. She went home and prepared for her fate. But the doctors were wrong. Years later, when I accompanied her to one of her routine medical checkups, I asked what had become of the results. I discovered there was no brain tumour. It had been a misdiagnosis. I shudder to think what would have happened had my grandmother consented to surgery.
Dr Tsoi was a long-standing family friend who had known my grandmother and her husband. He had a private practice, as most doctors in Hong Kong did, and performed a role akin to that of a general practitioner. Apparently he was influential in advising my grandmother not to support my mother’s ambition to train as a nurse, even though she had been offered a place. My mother told me years later that this was because he did not think she had the right temperament for it. I only ever met him when I accompanied my grandmother for her health reviews when in later years she was on beta-blockers for hypertension. I don’t remember him that well, but I do remember him advising very regular appointments, all paid of course, so that he would be in a position to issue the necessary paperwork when she died, without recourse to a post mortem. I am not sure how well-meaning that was.
In our final year at medical school, we were all encouraged to do a two-month elective in a different country, to widen our experience and to see medical practice from a different perspective. I wanted to return to Hong Kong, to see for myself how healthcare was being provided at home. I wanted, in particular, to see what psychiatric services were like, as I had often thought of our neighbour who lived upstairs and her regular admissions to the mental institution at Castle Peak. Queen Mary’s Hospital was the flagship teaching hospital in Hong Kong, so I wrote to them, but its medical school declined my request, on the grounds that psychiatric services were so basic it would not be beneficial to my training. Instead, they offered me consecutive attachments at their Obstetrics and Gynaecology and General Medicine departments.
The campus at Queen Mary’s Hospital in Pok Fu Lam was not very far from where my parents and grandmother were living, and it allowed me to return to live at home for the entire two months.
Medical student life was very different in Hong Kong; the student canteen was an incredible mosaic of noise and colour and smells, and a far cry from the student union building in the East End opposite the outpatient block at the London Hospital in Whitechapel. The choice of hot dishes was quite staggering. The young medics filled their trays with gastronomic delights whilst calling out to one another and squeezing around tables to join their friends and colleagues in an orgy of Cantonese chatter and Chinglish. Their lecture theatres were fully equipped too, and one could not hide amongst the 200-plus throng of students gathered to witness a clinical demonstration, or hear an eminent professor speak. Microphones on extended arms allowed every student who did not raise their hand to be the subject of humiliation when asked a question they could not answer. Medical training was a bit like that really – a mixture of humbling and emotional experiences, coupled with utter humiliation in front of fellow students, patients, doctors and nurses on consultant ward rounds, and years of hurdles, hoops and other obstacles to negotiate.
It seemed to me that my Chinese counterparts were extremely knowledgeable and academically superior. They were able to distinguish much more than the two sounds of the heartbeat on auscultation of the chest; they knew their applied anatomy and physiology backwards, and they seemed to know even the smallest minutiae of an uncommon or rare disease. I was quite in awe of their grasp, and wondered if I would ever pass my final examinations. But when it came to the art of patient consultation, to bedside manner, to speaking and treating patients, I felt the training I had in London served the practice of care and compassion in clinical medicine better. I have always believed that what one does not know, one can look up – but being a medical practitioner is an art, as well as a vocation.
I was amazed at the crowds of people waiting outside the clinic doors for a session to begin. The numbers of students in those government clinics was like a mini-theatre, with two to four rows of seats, whilst the patient and the doctor sat in front of the audience. The gynaecology clinic was like a cattle market; women were herded into a row of thinly-partitioned cubicles, and a curtain screened the doorway through which the patient would enter, undress from the waist down and lie in wait with her feet pointing to a drawn curtain directly opposite. We medics walked down the corridor, drew back the curtain, checked out the pre-screened history and proceeded with an intimate internal examination. We then closed the curtain and left. I don’t remember giving the patient any results; that must have occurred in another part of the clinic experience. To be fair though, it was very similar to the practice I witnessed as a medical student in Britain, only there were fewer cubicles.
The wealth of clinical material I saw on my elective was astounding; tuberculosis was rife, as was leprosy. We visited the 600-bedded Ruttanjee Sanatorium in Wanchai, one of the main institutions treating tuberculosis before outpatient chemotherapy was available, and the leper community in Lai Chi Kok. Leprosy thrived in the poor socio-economic environment of post-war Hong Kong, and those afflicted were compulsorily admitted for isolation and treatment. I shall never forget the men and women I met who had been blinded because of the loss of feeling they had in their eyes, which had allowed injury to go unnoticed and infection to spread; nor the lepromatous skin lesions in their faces and ears, and the nerve damage that came with the later stages of the disease. The stigma of leprosy was strong, but these people had been resettled from the isolated island of Hei Ling Chau (subsequently turned into a drug rehabilitation centre) into a relatively integrated community, although they still lived together. With the introduction of the World Health Organisation Multi-Drug Treatment regime, the successful elimination of leprosy in Hong Kong was officially declared in the mid-1980s, although there is still a population with an inactive form of the condition.