GOLDBLATT WENT TO THE Nailwright Hospital for his pre-interview the following week like a man voting in an election in Soviet Russia: knowing that the whole thing appeared to be about one thing whereas in reality it was about the direct opposite.
The first thing to grasp about a pre-interview was that it wasn’t an option. To stand any chance of getting the job, you had to go and visit the unit in the weeks leading up to the interview. But on the face of it, there was something dreadfully wrong with this. In fact if you thought about it objectively, it might even have occurred to you that pre-interviews undid virtually everything that the selection process was designed to achieve. Medical jobs in the NHS are public service appointments and are supposed to be allocated on merit alone. In theory, therefore, the process for allocating them is constructed so as to ensure fairness, objectivity, transparency, reproducibility, and the elimination of favour. Yet pre-interviews, sitting down for a private chat with a consultant on the unit that is offering the job, are all about subjectivity, clandestinity, absence of scrutiny, irreproducibility, and the currying of favour. There was a solution to this apparent paradox, of course, and as a Wise Man Goldblatt had eventually worked it out. To understand it, you had to start from one stop further along in the process, the medical interview itself.
An interview for a medical job is a unique ritual with a choreography all of its own. The first thing you notice about it is its sheer size. A medical interview is attended by a whole horde of important people, each of whom represents one of the many groups who can claim an interest in the appointment of a doctor. Excepting patients, of course, who can claim an interest, but not representation.
At an interview for a specialist registrar position Goldblatt would be confronted by a minimum of six interviewers on the other side of the table. First, there would be a consultant from the unit that was offering the job. Second, a consultant from the academic department of medicine with which the unit was affiliated. Third, a consultant with regional responsibility for specialist training. Fourth, a consultant representing the relevant specialist college. Fifth, a consultant representing the hospital. Sixth, to leaven this consultative load, a layperson acting as a moderator. But sometimes, depending on availability, the layperson turns out to be another consultant. Alternatively, for the sake of variation, the consultant representing the hospital occasionally turns out to be a managerial layperson. And sometimes, just to add to the fun, a few additional consultants from the unit offering the job turn up to view the goods.
And the point of having a panel large enough to field its own side in a variety of team sports? Fairness and transparency, the qualities that the selection process is supposed to enshrine. It’s fair to the candidate, fair to the hospital, fair to everyone who can claim a say. Every interest is represented, and how can anything underhand take place if six or eight people are watching?
On the other hand, how can anything useful take place? A panel of that size is just too cumbersome. So cumbersome, in fact, that firm measures are taken to prevent the whole procedure turning into a hopeless rout, and, more importantly, to ensure that no candidate’s appearance exceeds twenty-five minutes, which seems to be the main concern of the panel. Each of the interviewers is restricted to two questions, with the possibility of a supplementary. Yet it’s impossible to establish a sense of rapport, much less to develop a coherent understanding of someone’s thought processes, in the space of two questions. And having six people ask two questions each isn’t the same as having one person ask twelve. With all the chopping and changing, there’s no opportunity to probe, to delve, to discover. The interviewers themselves generally don’t do anything to make the best of the situation. They invariably converge five minutes before the panel is due to convene, and spend the next fifteen minutes exchanging hospital gossip until the moderator forces them to sit down. Tea is often provided, which makes it harder to get them started. Virtually impossible if there are biscuits. Few if any of them have had any formal training in interviewing techniques. There’s no coordination of the questioning. At least one of them – and usually more – discharges their duty by lighting randomly on a previous post in the candidate’s CV and asking him or her to describe the unit he or she worked on. The others all have a favourite stock question – The Social Issue, The State of the Health Service, The Research Programme – and their biggest worry is what they’re going to do if someone else gets in with the same stock question first.
The medical interview, therefore, is perfect, with the congealed, nostalgic perfection of something very beautiful, very fragile, and utterly useless. With its exquisitely balanced panel, paralysed by its own size, and its fastidiously designed procedure, mummified by its own rigidities, the interview is like a flawless Fabergé egg. And, like the most flawless, glittering Fabergé egg, it’s hollow. All is spectacle, and nothing is substance.
Yet medical interviews take place, and people are appointed, and jobs become vacant, and interviews are repeated. So how does the system function? Why doesn’t it implode into the vacuum of its own unblemished futility? For a very simple reason. Inside the dark interior of the Fabergé egg, away from the light and the glitter, is a little secret: the consultant from the unit offering the job has the veto.
Of all the consultants sitting at an interview table, the one who is actually going to have the successful candidate hanging around on their ward for a year or two has the right of refusal. Not the right of appointment – but the right of refusal. Yet in an interview that is designed so that no one can determine anything useful about a candidate, it amounts to the same thing.
Naturally, this generates its own perverse logic, as dark little secrets do.
One can’t possibly tell anything meaningful about the candidates for a job from the twenty-five flawless minutes of the medical interview, as everyone knows. But somehow, someone has to find out about them. And if the consultant from the unit offering the job has the veto, it ought to be them. So that consultant had better meet the candidates beforehand. They had better get to know them. They had better work out the reasons that they’re going to reject them if they have already decided who they want to give the job to. Quietly, in private, without anyone to watch or listen to the questions they’re asking. Without any of the golden horde that will troop in a week later and sit down around the table so that everything will apparently be fair and transparent and objective... after the one with the veto has already met the candidates and made up his or her subjective little mind without anyone to help or restrain the process.
That was the pre-interview. Something that was supposed to be about you getting to know the unit – but was actually about the unit getting to know you. You might get a perfunctory glance at the ward if you were lucky. Goldblatt had been to pre-interviews where the consultant simply sat you down in their office, pulled out your CV, and went through it. Not even the pretence of showing you the unit or introducing you to anyone else. After that you went home and came back a week later for the epilogue.
That was the pre-interview in its highest form, following the cruel logic of evolution to its ultimate stage. But it wasn’t until the day Goldblatt sat down opposite Professor Mike Coalport at the Nailwright Hospital that he understood just how cruel evolution can be.
At the appointed time, Goldblatt knocked on the door of an office on the fourth floor of the Nailwright. He heard a grunt, and a moment later the door was opened by a short man in his late forties. His belly hung over his belt, and his jowls were heavy, floppy, and pugnacious. He had a thick, light brown moustache, and receding hair that was curly at the sides, giving him the look of a debauched cherub. There were papers everywhere in the office, on chairs and cupboards and on the desk and on the floor. Coalport shook hands with Goldblatt perfunctorily and waved him towards a chair that was wedged against a wall between two tall filing cabinets that were stacked even taller with papers. The chair had its own pile of papers, but Mike Coalport grudgingly picked them up and dropped them on the floor in Goldblatt’s honour.
There was a larger, more comfortable chair in front of Coalport’s desk, but this was stacked with papers as well, and these were obviously too important to be moved for a mere job candidate. Goldblatt therefore sat in the offered chair, cramped between the two leaning stacks of paper that rose four feet above his head on his right and his left, hoping they weren’t going to fall on top of him, while Coalport himself sat down behind his crowded desk three yards away on the other side of the room.
Goldblatt didn’t know much about Mike Coalport, but he had seen plenty of doctors and most of the varieties of arrogance that they practise. The first minute in Mike Coalport’s office was enough to show him that he was in the presence of the meanest, hardest, most self-opinionated and injurious arrogance there is. Mike Coalport was the kind of doctor who prides himself on being known by his colleagues as a bruiser. He was at the height of his powers, more than capable of destroying the career of any trainee doctor who was foolish enough to cross his path. If Malcolm Goldblatt was a Wise Man, Professor Mike Coalport was an Eminent Physician. He wasn’t just an Eminent Physician, he was an EMINENT PHYSICIAN, and no one thought he was more EMINENT than he did.
Coalport glanced appraisingly at Goldblatt for a moment, like a secondhand trader about to offer a quarter of the value of a cherished heirloom to an anguished and starving widow. Then he picked up a sheaf of pages, glanced at it scornfully, flipped a page, and eventually fanned his face with it, as if it was a crumpled, stale theatre programme. From a play that wasn’t very good.
Mike Coalport said: ‘So, Dr Goldblatt. Have you done a research degree?’
And Goldblatt knew. He knew it. He was a Wise Man again.
Coalport was going right for the jugular, and he wasn’t even waiting for the interview. Goldblatt didn’t think he’d even bother telling Lesley about this encounter when he went home that night. It would only get her angry. May as well hold that back for when the inevitable happened at the interview. No point getting angry twice, particularly when it was about the same thing each time, only in different settings.
‘No,’ said Goldblatt. ‘I haven’t done a research degree.’
Coalport looked up at him in mock surprise, unable to conceal his contempt. It wasn’t even a contest. It was pitiful. Fancy coming along to get a job at the Nailwright Hospital – a certified Centre for Postgraduate Medical Studies – without even having done a research degree.
‘So I take it you haven’t done any research at all, then,’ said Mike Coalport, chuckling silently to himself at the absurdity of such a person turning up to work at the Centre for Postgraduate Medical Studies.
‘I haven’t done a formal research degree.’
‘So what have you done? Published a few papers, have you?’
‘Some.’
Mike Coalport put on his most derisive face and flipped a page or two of the sheaf of pages that he was holding. Goldblatt watched him fatalistically, and wondered what it was that could turn a man into such a beetle-like creature. The Egyptians made gods out of a certain species of beetles and called them scarabs, but that didn’t stop the beetles behaving as they had always behaved, slapping together balls of dung and rolling them home to eat in their tunnels.
‘These publications?’ he said, still staring at the sheaf of pages he was holding.
‘Which publications?’ asked Goldblatt.
Coalport looked up at him sharply. ‘These.’
‘Which?’
‘These! These ones listed here. What’s wrong with you?’
‘I can’t see what you’re looking at.’
Mike Coalport eyed Goldblatt suspiciously. ‘I’m looking at your CV. What do you think I’m looking at?’
‘I have no idea. You haven’t told me.’
Coalport sneered. ‘Are these your publications or aren’t they?’
‘Are they listed on my CV?’
‘Yes.’
‘Then they must be.’
Mike Coalport shook his head and huffed. He glanced pointedly at his watch. ‘Variation of Organ-Specific Autoimmunity with Disease Activity in Inflammatory Arthritis,’ he announced abruptly, citing the title of one of Goldblatt’s papers.
‘That’s mine.’
‘Wrote it with Sam Rothman?’
‘Yes.’
‘Tell me about it.’
Goldblatt told him. Mike Coalport had happened to choose the only one of Goldblatt’s four papers that was any good, the only one in which he took some pride, and which he had written because he genuinely believed it would add to the sum of scientific knowledge rather than because a consultant had urged him to write it for the sake of his CV. He had written it during his last substantive job, drawing data from Professor Rothman’s version of the Fuertler’s files that covered his disease of interest. Somehow he had managed to fend off Professor Rothman’s never-ending suggestions to cut corners or obscure confounders or overreach or over-interpret, or simply add undocumented figures that Professor Rothman swore he could remember, in order to make the paper ‘more interesting’. It was amazing, Goldblatt had discovered, how benign corruption could be, and how difficult to resist.
Coalport interrupted incessantly as Goldblatt spoke, challenging every point so that he had to make it again. Goldblatt made every point again, knowing that everything he had done in the paper was defensible. Only when he had heard each point twice was Coalport satisfied that there wasn’t some methodological or interpretational mine lying buried in there that he could explode in Goldblatt’s face.
But at the end Coalport shook his head with dissatisfaction. It wasn’t any good, it still wasn’t any good. That was obvious. It couldn’t be any good.
‘You don’t have any formal research training,’ he reminded Goldblatt helpfully, in case he had forgotten. ‘How do you know how to run a study or write a paper? You have to publish if you work at the Nailwright, Dr Goldblatt. But you haven’t learned the scientific techniques.’
‘Perhaps... it would help if I told you about one of my papers,’ Goldblatt suggested.
Coalport tossed Goldblatt’s CV on his desk.
‘A mere undergraduate degree in medicine isn’t enough if you want to make a contribution to the academic life of the Centre for Postgraduate Medical Studies. The specialist registrar is a clinical post, but you’d still be expected to make a contribution. It’s a highly academic environment.’
‘I’m not unfamiliar with academic environments,’ said Goldblatt. ‘I’ve also done a law degree.’
‘Was that before or after you graduated in medicine?’ Coalport countered swiftly.
‘Does it matter?’
Mike Coalport’s eyes narrowed. He gazed at Goldblatt for a long time, wanting to pick up his CV again, but feeling that it would be a sign of weakness if he retrieved the document that he had just tossed away. There was something unpleasant about this meeting, and Mike Coalport was beginning to suspect that it was beneath his dignity. Any meeting with someone who hadn’t done a research degree was very likely to be beneath his dignity. His first instinct was to walk out, pugnaciously, taciturnly, and disgustedly, as he often did at conferences after having delivered a withering intervention that left the speaker floundering for his notes. By walking out he could deliver a coup de grâce to this despicable job applicant who clearly deserved it more than the many conference speakers to whom he had delivered such coups in the past.
But walking out now would be tricky. After all, this wasn’t a conference hall. It was his office. He would have to wait around the corner and get his secretary to let him know when Goldblatt had left.
Finally he picked up Goldblatt’s CV again and nonchalantly turned a page.
‘This law degree of yours,’ he said, ‘was it a research degree?’
‘No,’ said Goldblatt patiently. ‘It was a law degree.’
‘Publish anything?’
‘It was a degree,’ said Goldblatt slowly. ‘A law degree.’
‘What sort of law degree?’
‘Torts.’
Coalport raised an eyebrow.
‘Negligence, litigation, criminal law—’
‘But it wasn’t a research degree!’ Coalport said with obsessive perseveration. Goldblatt was starting to wonder whether Mike Coalport was suffering from some rare form of early-onset dementia characterized by grandiose ideation, aggression, and frontal baldness. Coalport’s Syndrome. Why not? There was already an Alport’s Syndrome, why not a Coalport’s?
‘And what about this Free from Bondage thing?’ said Coalport, sneering sceptically at Goldblatt’s CV and almost spitting the words out. ‘What’s that, anyway?’
‘An NGO.’
‘An NGO, eh?’ Coalport snorted. ‘Publish anything?’
‘No,’ replied Goldblatt wearily, ‘I didn’t publish anything.’
Coalport shook his head in sham disappointment. What could he do?
‘I wrote a submission for the UN Subcommittee on Slavery.’
‘Did you?’ retorted Coalport jeeringly. Mike Coalport could tell a mile away when someone was trying to challenge him and was happy to meet them in combat anytime, anywhere. ‘And what was this submission about?’
‘Indentured child labour in Colombia. We called for a UN mission to go to Colombia to investigate the situation in the coal mines there.’
‘And did they?’
‘No.’
‘Well, it couldn’t have been much of a submission, then.’
‘No,’ said Goldblatt. ‘You’re right. The UN is usually incredibly responsive to demands made by small NGOs. It was a terrible submission.’
‘And you didn’t publish it?’
Goldblatt sighed. ‘No, we didn’t publish it.’
Mike Coalport smiled unpleasantly, watching Goldblatt with a bilious mixture of pity and contempt.
‘So all your papers are medical,’ he said. ‘You’ve done all these other things, yet you haven’t published anything. Not a single legal paper.’
‘Would it be better,’ Goldblatt asked, wondering if he had come for a job at the Coalport law offices by mistake, ‘if they were all legal?’
Coalport tossed Goldblatt’s CV aside. He shook his head. It wasn’t any good. It just wasn’t any good. It was even worse than before.
‘As far as I’m concerned,’ said Mike Coalport, ‘if you don’t publish, whatever you do is a personal indulgence.’
Well, thought Goldblatt, that was one way to give structure to your life.
‘You haven’t done a research degree.’
‘No,’ said Goldblatt. ‘I haven’t done a research degree.’
‘Well, you see, this is what shows, Dr Goldblatt. I’m afraid it simply does. I’m sure we’d all be very happy for you if you continued as you are and were able to get exactly the sort of specialist registrar job you want, but I’m afraid that’s very unlikely.’ Mike Coalport paused for a moment and gazed at Goldblatt with superiority and derision written all over his debauched cherubic features. When he continued, it was with the air of a man who is too busy for any more diversion. ‘I have fifty grant applications to review there,’ he said, sweeping his hand flamboyantly towards the pile of papers on the chair in front of his desk. ‘I assess grant applications for the BSM. Hardly one of those grant applications will be of sufficient scientific standard for me to even consider. Many of them come from people who have never done a research degree. I’ll be wasting my time.’
Goldblatt peered at the pile of papers.
‘What are you looking at?’ Coalport asked irritably.
‘Those grant applications,’ said Goldblatt.
‘Why?’
‘Is mine there?’
‘Have you lodged one?’
‘No.’
‘Then how can it be there?’ Coalport demanded.
‘It can’t,’ said Goldblatt.
That was the point. But Mike Coalport didn’t get it.
He gazed at Goldblatt, his lip curled in disgust. Then he stood up behind his desk. ‘I’ve heard enough.’
Goldblatt nodded. He guessed that Coalport hadn’t really needed to hear anything. He stood up too, being careful not to disturb any of the papers whose seat he had taken.
‘Something very odd happened to me today,’ said Dr Morris, standing in the doorway of the doctors’ office after Goldblatt had got back to the hospital.
Not as odd as what just happened to me, thought Goldblatt. Or maybe odd wasn’t the word.
‘I bleeped you to ask if you could see a patient for me, and Ludo answered.’ Dr Morris looked at him in surprise and horror.
‘What did you do?’ asked Goldblatt with interest.
‘I saw the patient myself.’ Dr Morris came in and sat on the edge of a desk. ‘I didn’t think... you know... Where were you, anyway?’
‘I went to the Nailwright for the pre-interview.’
‘With Mike Coalport?’
Goldblatt nodded.
‘How was it?’
Goldblatt thought for a moment. ‘Unpromising.’
Dr Morris laughed. ‘Mike Coalport’s like that. It doesn’t mean anything.’
‘I think it did.’
‘It doesn’t,’ said Dr Morris.
‘I really do think it did.’
‘I’m telling you it doesn’t. When’s the interview?’
‘Next week.’
‘Well, that’s his style. The more you think he doesn’t want you to get the job at the pre-interview, the more likely you are to get it.’
‘Then I’ve got it for sure,’ said Goldblatt.
Dr Morris had come up to the ward to examine Mr Lister, which he did a minimum of three times a week in the ever-renewed hope that something would eventually show up to explain his fevers. He also wanted to talk to Goldblatt about what they would do if the latest test revealed nothing. They were getting to the end of the investigational line, which was more of an investigational loop, because by now they were repeating tests that Dr Morris had already ordered, often for the third or fourth time. If nothing else showed up, they would have to make a diagnosis of exclusion: a diagnosis you make not from positive evidence, but from the absence of evidence, a diagnosis you make only because you’ve ruled everything else out. If the tests showed nothing at all to suggest a malignancy, a chronic infection or a specific inflammatory disease – which so far they hadn’t – the only possible remaining condition that could cause his symptoms would be a generalized, low-grade inflammatory condition, or vasculitis, and they would start him on steroids as the treatment.
Dr Morris wanted to explain this to Mr Lister himself. This was something the Prof would never have done. The Prof did her weekly round on Wednesday, and apart from that never came near the ward. In the time-honoured tradition of people who deal with problems at second hand in order to retain the option of blaming the people who are forced to deal with them at first hand, she would have sent Emma. Dr Morris, by contrast, was always arriving on the ward at the least excuse.
Yet something held him back in the doctors’ office. Maybe it was just the prospect of talking to Mr Lister, which seemed like merely another task when you were safe in your clinic room six floors down, but became strangely more dreadful the closer you got to his bed.
‘I’ve got no one today!’ he announced suddenly.
‘What do you mean, you’ve got no one?’ Goldblatt said. No one? What did that mean, no one?
‘There’s no one on the Sutherland unit. The house officer’s sick. The registrar’s away. And the locum SR walked out.’
‘When?’
‘Last night.’ Dr Morris looked at Goldblatt in genuine bemusement. ‘Why do they keep doing that? We’ve got so many fascinating patients.’
‘Ah...’ Goldblatt searched for a kind way to explain it to Dr Morris, and gave up. ‘No idea.’
‘Their loss. Anyway, I’ve got no one. I’ve just been seeing the patients.’
‘By yourself?’ asked Goldblatt incredulously.
‘There isn’t anybody else to do it.’
Goldblatt stared. It was unprecedented for a consultant to be alone on his unit. Or maybe it had happened once or twice before. During the Black Death, for instance, it may well have happened. But it was an unprecedented event within living memory for a consultant to be alone on his unit, even if it wasn’t really his unit. Yet Dr Morris had only himself to blame. Like a walking nuclear reactor, the pseudo-Sutherland pulsated stupendous waves of electromagnetic energy that attracted patients and drove everyone else away.
‘We’ve got thirty patients already,’ said Dr Morris, ‘and we’re on call from five o’clock.’
Goldblatt looked around the office for somewhere to hide.
Dr Morris grinned. He had obviously gone completely mad. And if he hadn’t gone completely mad, that just showed he was even madder.
‘Well, if you want me to help out...’ Goldblatt began lamely, having failed to discover any hidden trapdoors, ventilation shafts, or false cupboards into which he could disappear.
‘No,’ said Dr Morris cheerfully. ‘They told me they’d find at least two locums by five.’
‘What if they don’t?’
Dr Morris shrugged.
‘Well, I guess this is when you find out whether the thirteenth law works in reverse,’ said Goldblatt.
‘Which thirteenth law?’
‘The Fat Man’s thirteenth law.’
‘What are you talking about?’
‘In The House of God.’
Dr Morris still looked puzzled.
‘You know, the book. The House of God.
Dr Morris nodded. There was recognition somewhere in that nod of the dark, iconic book about medicine that had been published twenty years previously, but it was slow.
‘Remember the Fat Man?’
‘The fat man?’
‘The Fat Man,’ said Goldblatt. ‘In the book. The Fat Man’s thirteenth law: “The delivery of medical care means doing the most nothing.” Now you get to see if it works the other way round: “The more nothing you do, the more medical care you deliver.”
Dr Morris shook his head. ‘I never read that book.’
Goldblatt’s mouth dropped open. It was like listening to a man of thirty-six admitting he was still a virgin. Despite the fact that he had two children.
‘You never read The House of God?’
‘Someone gave me a copy. I read the first thirty pages and I stopped. It was just too cynical.’
‘Too cynical?’
‘Medicine isn’t like that.’
‘No,’ said Goldblatt.
‘You see?’
‘It’s worse.’
Dr Morris frowned. ‘Do you really think so?’
Did Goldblatt really think so? For God’s sake, The House of God was American. It had been written about interns in a well-known, lightly disguised American hospital. It was full of all kinds of American things. Like hope. There is no hope. There is no basketball court where HOs can shoot baskets together to drive the demons away. There are no policemen who sit around the Emergency Department all night offering homespun psychotherapy to terrified HOs who have lost all sense of self-worth. Evildoers aren’t redeemed. The system doesn’t slacken. People don’t find their niches. None of these things, which all happened in The House of God, happen in real life in medicine. Or at least not in Britain. In medicine, in Britain, real life was... Goldblatt searched for something desperate and miserable enough to depict the reality. There was only one word that could capture it. Ludo.
‘I love medicine, Malcolm,’ said Dr Morris. ‘I just love it. For me, there’s my family, and medicine. That’s all.’
‘What about squash?’
‘I could live without squash.’
Goldblatt laughed. But Dr Morris was serious. He was troubled. ‘Do you really think medicine is like that? Is that how it seems to you? Like The House of God?’
‘I told you, it’s worse.’
‘Really?’ said Dr Morris sadly.
Goldblatt looked at Dr Morris, who was gazing at him with an almost unbearable, childlike expression of dismay. ‘Say it ain’t so,’ his eyes seemed to be saying. ‘Mister, say it ain’t so.’
He wasn’t a bad man, Goldblatt thought. He had just done a round on thirty patients by himself, and he had probably taken their bloods as well. What greater love? How could you even think of such a man as bad? No, he loved medicine, that’s all, and medicine loved him back. How could he understand what it was to love medicine, but, for one reason or another, not to be loved in return?
But if that was a failing, it was of a type of which everyone is guilty, in some aspect of their life, at one time or another.
Besides, maybe Dr Morris was right, in a way. Maybe medicine wasn’t like that. For him.
He was alone on his unit. He was making history. The ship was going down in the Sea of Sutherland, and Dr Morris, all by himself, was doing his duty to the last. And he hadn’t even tried to force Goldblatt to come aboard. The least Goldblatt could do was to lie a little in return.
‘No, kid,’ Goldblatt said softly. ‘It ain’t so.’
‘Pardon?’
Goldblatt coughed. ‘No, I don’t really think it’s like that.’
‘Really?’ said Dr Morris.
Goldblatt hesitated. ‘Really,’ he said.