Chapter 2: A Doctor at Last

After six seemingly never-ending years of medical school, I had finally qualified as a doctor at the not so tender age of 30. On the way home, I stopped my car and had a good cry, a cry of joy and relief. It felt like a new horizon had suddenly opened up. Beyond it lay a future full of uncertainty, adventures and challenges. It was at once terrifying and elating.

Sure, there was much to be proud of; after all, I was now a doctor! But how would I cope with the pressures of the job? What if I turned out to be a dismal failure? Like most junior doctors, I was profoundly insecure about my abilities. Was I mature enough to be a good physician? So far, I had gained the impression that most people found me likable enough, but was this true or was I deluding myself? As much as I doubted others, I doubted myself even more.

The celebrations were long and wild, but even the most exuberant Bacchanalia must eventually come to an end. It was time to find a job. What on earth did I want to do with the rest of my life?

I had managed to navigate through school without ever working hard or taking it seriously. I had fallen in and out of love several times. I now was in a steady relationship but was nevertheless strangely unfulfilled. I had gone through medical school without serious problems. Thus I had proved to myself and the rest of the world that I was able to work hard and achieve things, if I had set my mind on them. My future as medical director of the family business had been mapped out for me since I was a child at my mother’s knee - yet I felt little enthusiasm for rushing into that career. I was not an indecisive person by any means, but now I had to confess that I was more than a little uncertain where I was going.

So far, I had been atypically hesitant about becoming a physician. Yes, I did want to follow in my father’s and grandfather’s footsteps, but it had never been an irresistible urge; and neither had I ever seen myself as a likely candidate to pursue an academic career. The decision to go into medicine had been difficult mainly because, first and foremost, I longed to be a musician. The moments of my life in which I had experienced intense happiness and weightless joy had occurred not during my years as a doctor in training but when I was on stage behind my drum-kit, playing together with inspired musicians. What would have been ideal was a life that combined both music and medicine, but these are both jealous lovers and neither could have been easily persuaded to move over and make room for the other. As it was, I felt torn between the two: the clinician in me was just taking his first diffident steps; the scientist had not even awoken, and although I was now undeniably a full-fledged physician - with a freshly-minted diploma to prove it - I still felt much more like a musician than a doctor.

To complicate things further, finding a junior doctor’s post in the late 1970s was far from easy. Germany had a surplus of physicians and the most attractive hospital jobs seemed to all be taken. With the help of our family doctor, I eventually found a position in a place that, at the time, was Germany’s only homeopathic hospital. Our family doctor had been a good friend of my mother for many years and, after hearing about my predicament, had phoned his colleague, the hospital’s director, who had promptly offered me this post.

Moving into homeopathy straight after medical school might have been an odd choice, yet it seemed fairly unremarkable to me. Our kind family doctor, who, like many of his German colleagues, often used homeopathic remedies alongside standard medicine, had treated me in this way since childhood. The impression I had formed through this early personal experience was that homeopathy was often effective. Most German physicians would use homeopathy with the vague idea that it somehow helped the body to heal itself. They would employ homeopathic remedies mostly for non-life-threatening, chronic diseases, particularly those for which conventional medicine had no cure (for example eczema, allergies, hay fever, sleeplessness, irritable bowel syndrome or headache). For more serious diseases, they would invariably turn to the standard armamentarium of conventional drugs.

As a young boy, I once fell acutely ill with colic of some kind. The pain was excruciating. Our doctor was called and treated it successfully by injecting a mainstream drug. Another time, I had caught a mild form of infectious hepatitis. He monitored my liver function and gave me homeopathic remedies. My liver subsequently normalized, and we all concluded that homeopathy had worked. I am sure this sounds utterly bizarre or even irresponsible to most modern physicians but, to me, it seemed entirely normal.

The relatively peaceful coexistence of homeopathy and conventional medicine in Germany is bewildering to people who have not grown up with this duality. How can doctors claim they are grounded in science and, at the same time, tolerate or even practise a type of medicine that is as remote from science as astrology is from astronomy? I am not sure that I know the answer to this question even now, and back then I had not yet started wondering.

As it was, my theoretical knowledge about homeopathy was close to zero. At medical school, homeopathy had rarely been mentioned but I had, of course, heard from our professor of pharmacology that this type of medicine was complete and utter nonsense. Pharmacologists tend to become particularly enraged when anyone mentions the “H-word” because homeopathy contradicts almost every single principle they teach.

Since I was about to start my job in the homeopathic hospital, I quickly read up about homeopathy. What I learnt was more than bewildering. In a nutshell, homeopathy is based on two main assumptions that were described by Samuel Hahnemann about 200 years ago. The first is often called the “like cures like” principle (similia similibus curantur, in Latin). Hahnemann asserted that, if a substance causes a certain symptom in a healthy person, it could be useful in treating these particular symptoms when they occur in a patient. This might sound elaborate or complicated but, in fact, it turns out to be surprisingly simple: because my eyes start watering when I am chopping onions, for example, onion is a homeopathic remedy for treating hay fever - which is, of course, characterized by watering eyes.

The second principle is often referred to as the “memory of water”. To use the above example of the onion as a remedy for hay fever, homeopaths do not use the pure onion extract. Instead they dilute and shake, and dilute and shake the extract many times over. They call this dilution process “potentiation” to indicate their conviction that it renders the remedy not less but more potent. Dilutions are often in steps 1:100, which is characterized by the letter C (centum is the Latin for one hundred). A typical homeopathic remedy is so watered down that it no longer contains a single molecule of the original substance. A ‘C30’ potency of onion, for instance, would contain 1 part onion extract in 1,000,000,000,000,000,000,000,000,000,000,000,000,000,000,000,000,000,000,000,000 parts of water. Another way to express this is perhaps even more explicit: for a “C30” pill to contain just one single molecule of the substance printed on the label, the pill would have to have a diameter similar to the distance between the earth and the sun. Once we have fathomed this simple premise, we can immediately see why scientists find homeopathy so hard to swallow.

Homeopaths acknowledge the fact that the repeated dilutions may indeed result in not one molecule of the original active ingredient remaining, but crucially they also claim that the repeated shaking - a process they call “sucussion” - transfers some sort of indefinable energy from the onion to the water - hence, the phrase “memory of water”.

When I began working as a physician in the homeopathic hospital I knew, of course, that homeopathy lacked scientific plausibility. There is no reason to assume that evoking similar symptoms will cure a disease and there is even less basis to the notion that diluting a substance will render it more powerful. But I was prepared to shrug my shoulders and concede pragmatically that if it helps, it helps. After all, I had benefitted from these strange remedies myself on numerous occasions. Perhaps my appointment as a junior doctor in a homeopathic hospital would enable me to get to the bottom of this paradox: on the one hand, homeopathic remedies could not possibly work; on the other hand, they clearly did help some patients to get better. This was an intriguing contradiction, and from that perspective alone the offer of working as a homeopath was a chance I didn’t want to pass up. As things turned out, the decision did indeed prove fateful; few of the many posts I took during my early career would turn out to have nearly such a profound and long-lasting influence on my professional life as this one.

* * *

The Munich homeopathic hospital was housed in a modern building set in a pleasant park in the southern suburbs not far from where my girlfriend and I lived. With only around 100 beds, it was a small but famous and respected institution. The hospital itself was extremely well-run; it was immaculately clean, there was an unusually tight discipline about everything, and the food was the best I ever ate in any hospital anywhere in the world.

In the entrance hall there was a big sign, “Here we do not smoke!”, which was not at all typical of hospitals at that time. In the 1970s, smoking was still allowed everywhere, even in hospitals and even on the wards. So the non-smoking policy was way ahead of its time. The wording of the sign was, however, unusual and somewhat patronizing, I thought. It did not simply say “No smoking” or “Please abstain from smoking”, but delivered its message in an Olympian tone, almost as a value judgment.

Everyone working in this place was very kind but, at the same time, my colleagues were often pushy, given to minding other people’s business and quite unashamedly on an evangelical mission whose goal was to convert everyone to the gospel of Samuel Hahnemann.

Being a “real doctor” was terrifically exciting - at times even more fascinating, I slowly began to feel, than being a musician. Initially, I was merely shadowing more experienced colleagues, but after a few weeks I was given more responsibility. What I saw was impressive. We were treating mostly chronic conditions, anything from asthma to rheumatoid arthritis and from migraine to obesity - lots of obesity. Despite the fact that we were dishing out remedies which, as my pharmacology professor had insisted, contained precisely nothing, patients usually did get better, some even dramatically so. I was bowled over! Soon I found myself treating my mother, siblings and friends for this or that minor illness. Even our dogs did not escape my enthusiasm for the newly discovered pilules containing sugar and... sugar.

Yes, I was impressed, but occasionally I also had doubts: was it really the remedy itself that was responsible for the recovery of our patients, or was it the careful, compassionate attention paid to the patients that brought about their improvement? Perhaps the patient would have improved even without any therapy at all? Crucially, was not every young doctor impressed when treating his first patients and watching them recover? Was I perhaps deluding myself about the powers of the ultra-diluted homeopathic remedies? These nagging doubts stimulated reflection and made me eager to explore further and learn more.

The medical director was frequently a tad tyrannical with his staff but he seemed to like me and took me under his wing. So we frequently had long discussions about all sorts of issues. His reply to my question “What precisely causes the improvement of our patients?” amazed me with its disarming honesty. “It’s mostly due to the fact that we discontinue all the useless medications they had been taking previously.” I had not previously thought of that possibility at all.

But it was true: we did scrap most of the unnecessary drugs. I was struck by the amount of nonsensical prescriptions many patients had accumulated during the often long years of their medical history. All these drugs did, of course, have the potential to cause side effects. Throwing them overboard was therefore quite likely to improve our patients’ symptoms, provided these drugs were truly superfluous. All this was hardly amazing and even my pharmacology professor would surely have approved. What was remarkable, however, was that my boss did not claim that his miniature homeopathic pellets were the prime reason for the improvement. Perhaps he did not himself believe in homeopathy? Such heretical thoughts!

The placebo effect, I suggested, might be another reason for homeopathy’s success. During my time in this hospital, I witnessed many instances of its amazing power. Once, during a ward-round, a patient experienced an acute asthma attack just as we were passing by her bedside. I had never seen anything like it; within minutes she seemed to suffocate in front of our very eyes. She was deteriorating fast into what I thought was a critical state. I was alarmed, if not panicked. My boss, however, remained strangely calm: “Don’t worry,” he told the patient, “we will give you an injection immediately. It will have an instant effect. Trust me; you will be fine in just a minute.” With that we all left the room; outside, the nurse was instructed to prepare a saline injection. This, we all knew, would have no effect at all; saline injections are pure placebos. I was told to go back to the patient and administer the injection intravenously. I was horrified: how could this help a patient on the brink of death? But when I argued my corner, my concerns were dismissed peremptorily.

So I did my best. On arrival at the patient’s bedside, I continued reassuring her that my injection was powerful and would be dramatically effective. And to my utter amazement, so it proved to be. Seconds after I had injected the saline, the patient began to breathe regularly, her colour normalized, and she relaxed.

“Never forget the incredible power of placebo”, my boss later told me. He was absolutely right, and I never did forget the importance of placebos. In fact, years later they actually became a focus of my research.

That first hospital job in Munich also taught me to practise a range of other alternative therapies besides homeopathy. I was usually taught new techniques by doing them, the expectation being that I would read up about the subject in my own time. A famous saying put it in a nutshell: watch one, do one, teach one. During my time at medical school, I had already attended courses in acupuncture and what was known as autogenic training, a method of self-hypnosis that teaches patients how to relax effectively. Now I learned elements of herbal medicine, of cupping, neural therapy, treatment with leeches and other exotic therapies.

One of my colleagues even practised dowsing, a bizarre diagnostic method. Whenever he was not sure which homeopathic remedy to prescribe, he would take out his pendulum and brood over that patient’s case notes until the swing of his instrument told him which the right treatment was. Even in the eccentric atmosphere of the homeopathic hospital, this was considered to be fringe medicine. We used to smile at this procedure and had our doubts about its validity. But nobody ever challenged him, or asked him to explain exactly how the swing of his pendulum could reliably resolve a thorny clinical or therapeutic dilemma. It was instances of this kind that, after a few months, began to kindle in me an increasingly urgent need to move on.

It had already occurred to me that some of my colleagues used homeopathy and other alternative approaches because they could not quite cope with the often exceedingly high demands of conventional medicine. It is almost understandable that, if a physician was having trouble comprehending the multifactorial causes and mechanisms of disease and illness, or for one reason or another could not master the equally complex process of reaching a diagnosis or finding an effective therapy, it might be tempting instead to employ notions such as dowsing, homeopathy or acupuncture, whose theoretical basis, unsullied by the inconvenient absolutes of science, was immeasurably more easy to grasp.

Some of my colleagues in the homeopathic hospital were clearly not cut out to be “real” doctors. Even a very junior doctor like me could not help noticing this somewhat embarrassing fact. One particular physician, for instance, made an extraordinary fuss each time she had to give an intravenous injection. Her inability to do this properly often resulted in pain, bruising and distress for the patient, generating a complaint - and this, of course, made her even more nervous and flustered the next time she was called upon to perform the procedure. Each injection thus became a major event disrupting the entire ward. In the interests of protecting the patients as well as preserving an atmosphere of peace on the ward, I decided to do the injections discreetly myself, before she even had time to panic. Once she had discovered that this task gave me no problems, she regularly delegated all the injections to me. Who knows whether she ever learnt to master that simple and essential technique?

One day, we were to perform a liver biopsy on a patient. This was a very big event in the off-beat environment of the homeopathic hospital, way outside our comfort zone. The task fell, of course, to the most experienced doctor, whom I volunteered to assist. Already during the preparations, he seemed exceedingly nervous. When he finally pushed the horrifyingly thick, long biopsy needle through the patient’s skin in the direction of her liver, he turned white and then promptly fainted. The patient was in considerable discomfort, and I was left attending to both of them. Eventually I attracted help and we managed to pull out the biopsy needle and obtain what looked like a decent tissue sample. The biopsied tissue was then sent off for analysis. Two days later, the report arrived on our desk. The first sentence was very disrespectful of our endeavours. “Thank you for sending us this ‘schaschlik’ (the German word for a mixed meat skewer one might order in a restaurant) for histological analysis.” It turned out that we had sampled bits of our patient’s diaphragm, lung and liver. Fortunately the patient was blissfully unaware of any of these problems; she had not experienced any suspicious symptoms and survived our incompetence quite splendidly.

* * *

I left the homeopathic hospital after about six months. Subsequently, I worked in several conventional hospitals in the areas ranging from general medicine to surgery and rehabilitation medicine. Eventually, I secured a post at the University of Munich in the Department of Rehabilitation Medicine where I was expected to engage in all three elements of university-based medicine: patient care, teaching and research.

I had never anticipated or planned an academic career but, when they offered me this post, I thought why not? It certainly fitted perfectly with my mother’s master plan of me becoming medical director of the family business, and she was delighted. In fact, both my parents were very happy: my mother saw things going very much as she had hoped for the family concern, and my father was pleased that at least one of his many children would follow him into the medical profession.

Most junior doctors have to work long hours and nights and, by then, I had done my fair share of that too. Now, my clinical work mainly consisted of looking after patients in a busy out-patient clinic. This meant marvelously regular working hours, starting at 8am and usually ending around 6pm. Best of all, there were no night or weekend duties. This gave me enough time for making music and for pursuing other interests. At this stage, alternative medicine had become somewhat of a hobby. I enjoyed hands-on training in massage techniques and spinal manipulation, and occasionally I also practised the alternative therapies with which I had already become familiar. Again, I was lucky: I had a very kind boss who soon became a close personal friend.

This was a peaceful, happy time for me, and an important period in my professional life. I found my feet, gained valuable experience as a clinician and became much more focused in terms of narrowing down a direction in which I hoped to develop. This was the time when I became a real doctor, able to differentiate between the important and the unimportant in patient care, capable of listening attentively to patients, confident in my abilities and able to cope with clinical routine as well as with the unusual events and crises that medicine always has in store.

During this period there was a surprise of quite a different kind in store for me also. Dramatically and unexpectedly, totally and uncompromisingly, I fell in love.

I was playing with The Jazz Kids at a gig in London. Danielle, a French woman aged 25, then living in London, came to the club where we were performing. At first, she assumed that I was a musician by profession. We talked, danced and were instantly attracted to each other. It quickly became more serious; attraction turned into passion and passion turned into love. I was entirely overwhelmed. To complicate matters, we were both already in relationships.

For a short while, we managed to keep our love secret. We both needed a little time to reflect. Were we really sure about all this? Perhaps it was just an infatuation? No, it certainly wasn’t. Neither of us had ever felt like this before; nothing else seemed to matter any longer and no obstacle could have stopped us. I simply adored her - and still do. We just had to be together.

The hardest thing was to tell our respective partners: neither of us wanted to cause pain. In comparison, the rest seemed almost easy: I gave notice at my job, informed my totally surprised mother, brother and sister, packed up a few things, drove to London (stopping at my father’s house on the way), rented a flat in Chelsea, and started a new life with Danielle.