JOBS IN THE MEDICAL profession are about patronage, and Goldblatt knew how patronage works. He also knew that he had no one to blame but himself for the fact that he had failed to take advantage of it.
The medical patron is a consultant, preferably a professor, with whom you develop your relationship as a registrar or SHO. They pulls the levers to get you your next job, find you a place to do your MD, and generally lean on people in your favour. In return, you perform the small acts of homage that a patron expects from their client. You treat them with the respect due to a great teacher, dance attendance whenever they arrive on the ward, put their name on every publication you produce even if they have zero input into it, and treat their private patients without a murmur.
That probably doesn’t sound like much of an incentive for the patron, and you might wonder why they bother. But just as their peers will judge them by the number of papers they publish, the number of beds on their unit, the make and model of their car, so they judge them on the number and quality of their clients. A patron who has seeded his or her little neck of the medical woods with a succession of consultants who owe their training and positions to them is the equivalent of a big swinging dick on a bond trading floor.
It takes influence to be an effective patron, and there are only a limited number of consultants who are sufficiently powerful to play this role. On the other hand, there’s a virtually unlimited number of young and aspiring doctors who want to be clients. The patron is therefore in the position of being able to choose which clients they will support, and which they will reject. Or to put it another way, it’s a patron’s market.
This was a very important point to bear in mind if, like Goldblatt, you were looking for one.
Goldblatt knew he had never been an attractive proposition as a client. Patronage isn’t there to help people buck the system. It is the system. A consultant has little to gain by backing a registrar who doesn’t want to do a research degree. It will take a cruel and unusual amount of influence to secure advancement for them, and the favours asked in return by other consultants are likely to be just as cruel and unusual. The legal interruption to Goldblatt’s medical training had also severed many connections at a sensitive time in his career, and had put him back at square one in the competition for patronage. Yet despite this, Goldblatt had almost succeeded in acquiring a patron in the person of Sam Rothman during the year that he had worked as a registrar on his unit.
Professor Rothman was perhaps not the greatest heavyweight in his specialist area. He had a habit of answering with anecdotes when he was asked questions about concepts. One of his favourite stories was about the time he almost got a bean in his eye.
Goldblatt first heard it on one of his ward rounds. The house officer was looking particularly unwholesome, making everyone queasy with the unpleasant post-mortem pallor of his face, and explained that he had had no sleep at all while on call the night before. Professor Rothman laughed heartily, brought the round to a halt in the middle of the ward, leaned one elbow on the notes trolley, and nostalgically recounted the tale.
‘I remember the day after my first night on call as a house officer,’ he began. ‘I hadn’t got a wink of sleep, just like young...’
‘Richard,’ whispered Goldblatt.
‘Like young Richard here. Not a wink. If I did, I was too tired to remember it!’
Professor Rothman laughed. He threw an amiable glance at the patient in the next bed, who was listening with interest as she waited for the doctors to reach her.
‘Anyway, I had a girlfriend at the time,’ Professor Rothman continued, as Richard closed his eyes and began to rock on his feet. ‘She’d invited me to her place for supper. That very night! So I sat down, and she brought my plate of soup out and then she went back into the kitchen to get her own. I can remember seeing her go out, and that was the last thing I did remember. I don’t know why she hadn’t brought out the whole pot – maybe she didn’t think it would be polite. At that stage we still didn’t know each other very well.’ He paused and gave a small sigh. ‘Anyway, out she went to get her plate, and when she came back she found me face down in the soup. She’d only been gone for a minute, but I was so tired I’d keeled over and gone to sleep!’
Professor Rothman laughed merrily at the anecdote. Dr Serenstern, the SR, smirked. Goldblatt stared at Professor Rothman incredulously.
‘Did you drown?’ he asked.
‘No,’ said Professor Rothman with avuncular bonhomie, ‘but I almost got a bean in my eye!’
Still, Professor Rothman wasn’t without clout. He was very nice and sometimes amusing, and these blameless attributes made him generally liked, and even bought him a moderate degree of influence. The sheer number of papers that carried his name, produced by the hordes of clients who attached themselves to him, also had an effect. Many of these papers, as everyone knew, were of doubtful quality, being derived from clinical records that were rarely complete, and they often appeared in second-tier journals that couldn’t attract anything better. But there were a lot of them. Professor Rothman also ran a lab from which emerged papers of better quality that appeared in journals of higher regard. So he had been able to ensure that his current SR, Dr Serenstern, who had first arrived on his unit as a registrar, had received a grant to do an MD in his lab and had then gone on to his current post. It was also common knowledge that Dr Serenstern would get the consultant position that would become vacant in a couple of years when one of the other consultants on the unit, Dr Bracket, retired. Dr Serenstern, who had been told by Professor Rothman to keep it all under his hat, smugly pretended to be worried about his future.
After Goldblatt had been on the unit for a month or two, Professor Rothman started coming up with ideas for a few doubtful papers that would add to Goldblatt’s publication record, and he gave Goldblatt access to his equivalent of the Fuertler’s files so he could write them up. He began mentioning rumours that he had heard on the grapevine about SR positions that would be falling vacant, and began speculating about which ones might be best for him. For a while it looked as if Professor Rothman was prepared to throw around whatever weight he had in order to help Goldblatt get an SR job.
But wouldn’t he need to do a research degree, at the very least an MD? No, Professor Rothman declared, not with his backing.
Unfortunately for Goldblatt, Professor Rothman’s greatest strength was also his greatest weakness. The core of his niceness was an acute and overwhelming agreeableness, reflecting the fact that Professor Rothman’s opinion on any matter strongly tended to echo the last opinion he had heard on the subject. His attitude underwent a change that coincided uncannily with the first SR interview that Goldblatt went for, and in particular with a phone call from one of the members of the interview panel that he received the day afterwards. The interviewer, who was a personal friend of Sam Rothman, had rung to let him know that the panel thought that Dr Goldblatt, while clearly an intelligent man and capable clinician, needed to do an MD before applying for any more SR posts. The panel, said the interviewer, thought Sam would want to know its opinion since he had been so strongly supportive of Dr Goldblatt’s application. Sam did want to know its opinion, and was very grateful to his friend. Professor Rothman called Goldblatt into his office and, in a fatherly voice, said that the interview just proved what he had suspected all along: Goldblatt needed to do an MD.
‘An MD?’ Goldblatt looked at Professor Rothman suspiciously. Professor Rothman nodded. ‘An MD?’ But this was the very man who, one month earlier, had assured Goldblatt that it was certainly possible to get an SR job without having an MD – as long as he had his backing – and if he didn’t get this job he would certainly get the next. This was the very office in which he had said it! ‘An MD?’ This time Professor Rothman looked at him blankly, as if he couldn’t remember any of the things he had told Goldblatt earlier, and didn’t particularly want to be reminded.
In fact, there was a deeper message. When the consultant from the interview rang, it wasn’t simply to tell Professor Rothman that Dr Goldblatt needed to do an MD. There was a subtext, which was that Dr Goldblatt, more than anyone, needed to do an MD. That was the only way he could remove the doubt that hung over him now that he had been outside the fold. It was the only way he could prove that he had really come back for ever. He had to do it harder than everybody else, be purer than pure Otherwise, the stain on his record was going to stay there for good.
Goldblatt understood the message now, as clearly as if it were written in front of him. Had he really failed to see it back then? Or had he simply refused to acknowledge it?
But Professor Rothman wasn’t cutting him adrift. Not at all. He mentioned the idea of applying for a research grant with Goldblatt. Perhaps Malcolm could do an MD in his lab, as Dr Serenstern had done. But Professor Rothman, an indiscriminate and therefore unreliable patron, had offered the identical gift of a place in his lab to other clients as well, and a lab has only so many places to go around. And Goldblatt, an unwilling and therefore unreliable client, didn’t really want to do an MD anyway. So the idea drifted along for a while without anything happening, as different grant applications were written with different, more enthusiastic registrars, and might have drifted along for even longer had not an event taken place that was to kill Professor Rothman’s patronage stone dead.
This event, as such events are, was the end result of a long chain of preceding events that culminated in a particular place at a particular time. Had it culminated earlier, or later, or somewhere else, it would have had no effect at all on Malcolm Goldblatt, and who could say how the course of his life might have been different? But it culminated when it did, and Goldblatt was standing slap bang in its way.
To summarize a long and bitter political struggle, the cardiologists, who had been agitating for years to withdraw their registrars from the medical Take rota, suddenly achieved their objective. This meant that the on-call commitments of the Cardiology registrars had to be redistributed amongst the remaining registrars on the staff. Someone in Medical Administration, whom Goldblatt had never met, sat down, drew up a new rota, and sent it out. And that person, whoever it was, probably expected to hear no more of the matter.
Goldblatt didn’t want to do any more on-call work. It wasn’t a huge amount more that he was expected to do – just an extra night every couple of weeks – but his contract specified exactly how much on-call work was required from him, and this wasn’t included. So he went to talk to Dr Oakley, who was the consultant on the unit who ran the administrative side of things.
Dr Oakley was a generally compliant character who would have liked to see every side of an argument, but couldn’t, now that his life had become a continuous series of skirmishes over the running of the unit. This role had been more or less forced on him by his two colleagues. Professor Rothman had academic interests to attend to, and Dr Bracket was too long in the tooth to bother with any of this new-fangled management hoo-hah, so if anyone was going to do it, it was going to be Oakley. When it all got too much for him, Dr Oakley would spread his papers out in piles on the floor in his office and go down on his knees, trying to sort out his correspondence. Often when Goldblatt walked past his office he would see him down there mumbling to himself in despair.
Goldblatt had a good relationship with Dr Oakley. He thought – he really did think – that Dr Oakley would recognize that the demand for him to do additional on-call work was a simple, straightforward breach of his contract, and that would be that.
Dr Oakley did recognize that it was a simple, straightforward breach of Goldblatt’s contract and said he’d talk to the appropriate person in the hospital management. He talked to the appropriate person in the hospital management and came back and told Goldblatt that all the other registrars had readily agreed to the change, which Goldblatt found interesting, and quite sad, but hardly relevant. All right, said Dr Oakley, and he went back to the appropriate person, and the appropriate person sent him right back, and this time Dr Oakley asked Goldblatt if he wouldn’t change his mind, ‘just for me’. Sorry, said Goldblatt. All right, said Dr Oakley, and said he’d respect Goldblatt’s decision – which he respected for about a day, until he went back to the appropriate person and she told him she couldn’t possibly stand for that kind of insubordination and she didn’t understand how Dr Oakley could either. At which point she declared that she was prepared to come and talk to this troublesome Dr Goldblatt if Dr Oakley thought it would help. Dr Oakley didn’t know if it would help but he didn’t think he was being given much choice in the matter.
When Dr Oakley told Goldblatt that the appropriate person wanted to talk to him – but there was still time to avoid this terrible meeting, if only he’d change his mind – Goldblatt sensed that he was being intimidated. A few seconds after that, he sensed that he was standing up for a principle. Once he realized he was standing up for a principle, there was no way he could back down. By now Dr Oakley couldn’t back down either, but in his case it was less of a principle and more of an expediency.
So Goldblatt got to meet the appropriate person, who turned out to be a dumpy, pasty woman who introduced herself as Sue Bigelow, wearing a dark suit, with dyed blonde hair, and a lot of foundation on her face. And a small folder under her arm, which she opened officiously as she sat down in Dr Oakley’s office with Oakley and Goldblatt, as if to declare that the meeting was open.
Dr Oakley, Goldblatt noted, had cleared away all the papers from his floor for the occasion.
Sue Bigelow seemed genuinely surprised at Goldblatt’s refusal to work the extra shifts. ‘Why don’t you tell me why you don’t want to?’ she said, as if talking to a four-year-old.
‘Because I don’t,’ replied Goldblatt, happy to play the part.
‘We’ll pay you.’
‘I don’t want the money.’
Sue Bigelow shrugged. All right, the hospital wouldn’t pay him.
‘No, you don’t understand,’ said Goldblatt, ‘I’m not going to do it.’
Sue Bigelow looked dumbfounded. She glanced at Dr Oakley. Dr Oakley looked back at her helplessly.
‘Why do you say you’re not going to do it?’ Sue Bigelow asked eventually, as if she was really interested.
‘Because I’m not,’ said Goldblatt.
‘Why not?’
Goldblatt sighed. Why explain? He had given his explanation twice already to Dr Oakley, which was once more than he ought to have been asked to.
‘Let’s try to see how we can reach a solution that’s acceptable to both of us,’ said Sue Bigelow in a controlled, reasonable, but firm tone, just as they had taught her at management school.
‘All right,’ said Goldblatt. ‘Let’s start by saying I’m not going to do it.’
‘Why not?’
‘Why don’t you read my contract?’
‘I have read your contract, Dr Goldblatt.’
‘Good. Then you don’t need to keep asking that question.’
‘This is a hospital. We have to think of our patients, Dr Goldblatt, not just our contracts. We can’t let the patients suffer.’
‘The patients won’t suffer,’ Goldblatt replied in what he thought was a controlled, reasonable, but firm tone, which he imagined Sue Bigelow would appreciate. ‘You’ll hire locums for the extra nights. There are plenty of registrars doing research who want the work. I can give you some names if you need them. And then you won’t find yourself in the position of trying to breach my contract, which must be very unpleasant for you.’
Sue Bigelow frowned. She looked down at her file and made a note with her pen. Perhaps, thought Goldblatt, she was writing down his excellent suggestion. No, he thought, surely that one would have occurred to her already.
But it really was an excellent suggestion. The only drawback to it was that it would cost the hospital somewhat more to hire locums than if they could coerce Goldblatt – who was paid only half his usual rate of pay for on-call hours – to do the work. Given the small number of nights they were talking about, the total sum at stake for the hospital over the course of the rest of the year was probably all of a couple of thousand pounds. Thus it was preferable, it seemed, to try to breach his contract.
Sue Bigelow looked up at him. ‘It’s not very much more we’re asking you to do,’ she said, back in her cajole-the-four-year-old tone.
‘For who?’ asked Goldblatt.
She looked puzzled. ‘For you.’
‘Oh. For me? Who are you to make that judgement?’
Sue Bigelow folded her arms in exasperation. Now, she was getting angry. She shot a cold glance at Dr Oakley. What was wrong with him? Couldn’t he control his junior staff? Dr Oakley caught her glance and looked away quickly. This was going to get back to the Chief Executive and it wasn’t going to do him any good. He glared at Goldblatt resentfully.
Sue Bigelow turned back to him. ‘Dr Goldblatt. I am always open to suggestions. But understand one thing. I refuse to discuss issues with staff who have already made up their minds and will not consider alternatives. I am prepared to consider alternatives, but I will not speak to people who will not consider alternatives themselves.’
‘Does that mean I can go?’ asked Goldblatt.
‘No, you can’t go.’
‘But I’ve told you I’m not prepared to consider alternatives. Doesn’t that mean you refuse to talk to me?’
‘Malcolm...’ said Dr Oakley.
‘No, Andrew,’ said Sue Bigelow. ‘I think Dr Goldblatt needs to understand this very clearly.’
‘I don’t understand this very clearly,’ said Goldblatt. ‘I’m very confused. Why did you ask me to come to this meeting if you were going to refuse to talk to me?’
‘Dr Goldblatt, listen to me. I will not discuss an issue with staff who will not consider alternatives.’
‘So I can go.’
‘Maybe he should go,’ said Dr Oakley.
‘No, Andrew,’ said Sue Bigelow, who had come to show Dr Oakley how to deal with his staff, and was determined to do it. ‘Dr Goldblatt, nothing I have heard today shows me that you care anything at all for this hospital or its patients.’
Goldblatt restrained himself. He glanced at Dr Oakley. Oakley looked away before he could meet his eyes.
Goldblatt turned back to the manager who was sitting with her folder still open on the desk in front of her. ‘You should be careful before you say that sort of thing to a doctor,’ he said quietly.
‘And what is that supposed to mean?’
‘You should think before you say things like that. That’s all. And speaking of caring for patients, I think I’ve wasted enough of my time with this ludicrous conver—’
‘Do you care for your patients, Dr Goldblatt? Perhaps you’d care to prove to me that you do.’
Goldblatt glanced at Dr Oakley again. Again, Oakley avoided his eyes. What was wrong with him? Was he going to sit by and let some over-rouged manager impugn his own registrar? Oakley had worked with him. He knew whether Goldblatt cared or not.
But Andrew Oakley just sat there, his ears going red and his eyes fixed firmly on the floor, as if he wished his papers were still down there.
‘You don’t understand what it is to do on-call work,’ Goldblatt said eventually.
‘I think I do,’ said Sue Bigelow.
‘Tell me when you’ve ever done it. Which hospital? What rotas? One in three? One in four?’
‘I don’t think that matters.’
‘Then you think wrong.’
‘Then explain it to me.’
‘Why should I bother?’ Goldblatt didn’t care enough about this person who already knew all the answers to explain one of the answers that she obviously didn’t know.
‘Because I asked you.’
‘So?’
‘Malcolm...’ said Dr Oakley.
‘No one who hasn’t done it can understand what it is,’ said Goldblatt wearily. ‘All right? Take it from me. How many times have you stayed in this hospital for thirty-six hours straight? For sixty hours straight? When you’ve done it ten, twenty times, thirty times, then let’s sit down and have a talk. But right now, until you’ve done that, you may think you can understand, but you can’t. That’s a piece of advice. Use it as you will. You may find it helpful the next time you try to make someone do something you’ve never done yourself.’
Sue Bigelow didn’t want Goldblatt’s advice. She threw a knowing glance at Dr Oakley. He managed a sickly smile in return.
‘I think I can understand it,’ she said.
‘Good for you,’ said Goldblatt, who was a long way beyond giving a fuck about what she thought she could understand, but knew that he was going to hear anyway.
‘I think most women can. Any mother who has ever had to nurse a newborn baby can understand it.’
Goldblatt stared at Sue Bigelow with genuine astonishment. Then he glanced at Dr Oakley to verify whether he really had heard what he thought he had heard. This time, Dr Oakley was too stunned to look away. He gave a slight, amazed shrug in response to Goldblatt’s glance.
Well, whatever happened now, thought Goldblatt, this meeting wasn’t going to have been a total waste of time. It had been worth sitting through all the condescension and threats for this one surreal moment.
Sue Bigelow was watching him with a smugly triumphant smile.
‘Do you think,’ Goldblatt said eventually, really wanting to find out if it were possible, ‘do you really think you can compare my relationship with the six hundred patients who are in this hospital on any given night, most of whom I’ve never even met, to the relationship a mother has to the baby to whom she’s given birth? Is that how you see it: they’re my babies and I’m their mother? All six hundred of them? Is that really how you understand what goes on in this hospital every night after you leave your little office, after you lock your little door, after you go home to your little family?’
Sue Bigelow blinked.
Goldblatt grinned. ‘If that’s your idea of motherhood, are you sure you’re fit to bring up your kids?’
And then he started to laugh. It was so ridiculous, he couldn’t stop. Sue Bigelow stared at him with cold, rigid fury. Goldblatt was still laughing as he got up and left. Out of the corner of his eye, he saw Dr Oakley’s shoulders shaking with silent giggles.
But Goldblatt never forgave Dr Oakley. Silent giggles didn’t wipe out his guilt, his failure to speak up when it mattered, or what he did later.
Goldblatt had won. He didn’t do the extra shifts. There were no legal grounds on which he could be coerced. The hospital gave the work to a couple of research registrars, who thanked him for the chance to earn some extra money.
But he lost as well. A lot more than he won. Dr Oakley had been humiliated, first by Goldblatt, then by the manager, then by Goldblatt again. The knowledge that he should have stood up for Goldblatt in the first place only added a prickle of self-loathing to the contempt he sensed from Sue Bigelow and the inadequacy he felt in trying to cope with his administrative role. And whose fault was that? Goldblatt’s, of course. Why couldn’t he have just agreed to do the few extra shifts like every other registrar in the hospital?
And having misjudged what Dr Oakley would do the first time around, Goldblatt misjudged him again. As Lesley said, he never anticipated that people would actually act on their anger, that they wouldn’t just laugh the experience off as yet one more absurdity the world threw at them. That very deliberately, purposefully, they would do something to injure him.
Naturally, Dr Oakley often spoke with Professor Rothman. When he spoke with Professor Rothman, he expressed his opinion about all sorts of things. He expressed it about Dr Goldblatt. Until now, Professor Rothman had had a generally favourable opinion of Dr Goldblatt. But Professor Rothman never had an opinion of his own that couldn’t be reversed by a more forcefully presented opinion of somebody else.
Professor Rothman reversed his opinion.
There was no more talk of an MD in Professor Rothman’s lab.
Goldblatt didn’t know that he really blamed him. Sam Rothman wasn’t much of a patron, but to be fair, Goldblatt had to admit that he hadn’t been much of a client. He had been right on principle but wrong in practice. A good client would have acceded to Dr Oakley’s demands in order to protect his relationship with Professor Rothman. Goldblatt didn’t. Hence, in the context of a patronage system, he deserved what he got.
The day he left Professor Rothman’s unit five months later, with Dr Oakley glancing out of his office from time to time to see if he was finally gone, he stepped patronless, MD-less, into the cold, cold world of locumdom.
Twenty months of it, including the time he had spent so far on Professor Small’s unit. And unless some miracle was about to happen at the Nailwright Hospital the following afternoon, it was twenty months and counting.