The orthopaedic surgeon instructed me to take a history and examine the patient for later presentation. As I prepared to take a history I was already working through my mind what could have brought a young man to the orthopaedic ward.
I began by asking him what he was doing in hospital, to encourage him to speak openly about his condition. He told me that he had come back from traditional initiation school in the Eastern Cape. He was bright and well spoken, and he’d been briefed not to give the diagnosis away. The sparkle in his eye told me that he enjoyed the momentary wrinkling of my brow as I wondered what on earth his traditional circumcision had to do with his orthopaedic problem.
I tried again. “Bhuti, what happened to bring you into hospital?” I asked.
“I went to the bush for circumcision,” he said again.
I realised I needed to adjust my approach. I thought that perhaps if I heard him out, gave him some room to tell me about his initiation, he would eventually get to the real reason he was in hospital.
“What happened while you were there?”
“I got very sick,” he said.
Initiation schools were notorious – and still are – for their unhygienic practices and the harm that young men come to when there. Every year there are reports in the newspapers of sepsis and even deaths that occur at the more dubious of these schools. If this patient had fallen ill, then it was most likely a septic circumcision wound. But what did that have to do with his bones and joints?
I continued to probe but I gleaned nothing more than his tale of botched circumcision; apart from that he’d been fit and well, and had suffered no other injuries.
I proceeded to examine him, all the time wondering what I was going to tell the surgeon when the time came to present the case. I ran through what I knew of his story, and tried to match it to the physical findings that were emerging. Most of the large joints of his arms and legs had limited movement, and he had a healing scar on his right shin. A picture was beginning to form in my mind, though it remained frustratingly out of focus.
“What happened here?” I asked, pointing to the scar on his shin.
“There was infection in the bone inside,” he said.
In that instant the picture became clear as the pieces of the puzzle slotted into place. His circumcision wound had become infected and the sepsis had entered his bloodstream, where it spread out to his joints and his tibia. When the joints healed the damage had caused them to become fused, which limited their range of motion as I’d found on examination. This young man had suffered a terrible ordeal just as he was embarking on his journey of manhood. Now he was lying virtually immobilised in bed.
As a student I learned a lot from that patient. His assertion right at the beginning of our interaction had held all the clues to what was ailing him; I had been preoccupied with my own ideas of a differential diagnosis, and had been too quick to dismiss what seemed like an irrelevant detail. That young man sensitised me to the importance of listening to my patients’ stories, as they held the clues that would help me in treating them.
Sometimes arriving at a diagnosis was a secondary concern, at least from the patient’s perspective. But as a student I was chasing a diagnosis, an outcome that I could study and analyse. I learned to cut through the fluff, to work quickly in my quest for answers. But in the process I sometimes missed out on the true value of my interaction with patients. This fact was brought home to me during my gynaecology exam at the end of fifth year.
I was allocated an elderly woman with extensive cancer of the cervix. She was from the Eastern Cape and had come to Cape Town to seek treatment for the condition.
I had less than 30 minutes in which to take a clinical history, examine the patient and polish up my notes for presentation to the two examiners. It was a terrifying prospect and I knew that I had to make the most of the available time.
I got straight to the point. “Mama, tell me what the problem is.”
Mama wasn’t working according to my agenda, and understandably so. She was unwell, had received a terrifying diagnosis. She knew nothing about fifth-year exams; I imagine even if she had known she probably wouldn’t care.
“I don’t know,” she responded absently.
Slowly I managed to extract from her that she’d been bleeding heavily, had experienced increasing pelvic pain over a number of months. She kept trying to tell me about her children; she had many and she struggled to remember when each of them was born. I cut her off each time she wandered to them; I needed a clean and succinct reproductive history, not a drawn-out account of her life as a mother.
When I examined her internally I found a large tumour on her cervix, which had spread to the surrounding structures. I also saw the fear in her eyes. Thinking back I realise that in the old lady’s insistence on talking about her children she was trying to tell me about what mattered to her, about the children she’d borne in the womb that was now riddled with disease. All she wanted was to be heard. But I had no time to hear her; what mattered to me was getting to the bottom of her diagnosis.
What I did not realise then was that this would be the trend in the years to come. Over the years I had little time to listen to my patients; to really hear them. I worked in very pressured environments and I was forced to strip away the colour in the stories of patients’ lives to get to the black and white of science and fact.
It is counterproductive to the therapeutic process that so often in our over-subscribed and under-resourced health care facilities the doctor-patient interaction – which is the very epicentre of treatment and care – is such a rushed affair. The therapeutic partnership is reduced to little more than a hurried transaction in which both partners are left wanting. Patients walk away dissatisfied that their complaint was either medicated or dismissed, and the doctor is left feeling that the need for expediency robbed them of the opportunity to truly make a difference in the patients’ lives.
As a trainee doctor I didn’t yet appreciate how keenly I would feel cheated later in my career.
But even in the midst of the rigour, humiliation and tough lessons, our training also had moments of magic.
I wasn’t anticipating anything but cold wretchedness one morning in July 1998 when I heard my alarm clock going off at six o’clock. It was Sunday morning and I could hear the faint pitter-patter of the winter rain against by bedroom window. This was snuggle-deeper-under-the-duvet weather and I didn’t feel up to the seven o’clock ward round that I was due to attend at the neonatal unit.
I’d anticipated this feeling the night before and had prepared by positioning my alarm clock as far away from my bed as possible so that I would be forced to get up to turn it off. I slowly heaved myself out of bed, begrudging myself my foresight yet knowing that it was futile to resist. I showered and changed, and then ate a minimal breakfast of tea and toast, telling myself that as soon as my duties were done I would come straight back to bed where I belonged.
The five-minute drive to the hospital did little to lift my spirits. The rain had intensified and the wind was driving it horizontally against the windscreen of my car. The deserted streets between my flat in Rosebank and the hospital in Observatory were a mere tracing behind the sheets of rain, and as I turned left into Anzio Road I hankered after the warmth I’d left behind. My clothes were drenched in the short run from the parking lot to the entrance of the Old Main Building, and I cursed the hellish start to the day.
As soon as I stepped into the neonatal unit I was mesmerised. The room was toasty warm and dotted around it were a number of incubators, each housing a tiny newborn baby. There was gospel music playing on the radio, and the nurses hummed softly in harmony as they went about their duties. It felt as if I had stepped onto hallowed ground, and all my yearnings