Growing Into Medicine (18 page)

He chose to be entirely responsible for driving the boat and caring for the engine. I cleaned and polished but took pleasure in the fact that he was in charge. The paradox of our life together was that he appeared to be in control, but in our day-to-day life I took the decisions, bought and cooked the food, paid all the bills, changed light bulbs and tightened loose screws. During those waterway holidays, alone or with Helen, he was able to forget his prisoners for a while and pay more attention to us. With the balance of power between us subtly altered, our marriage felt stronger.

12

Family Planning Provision and Training

A network of family planning clinics had been started by the National Birth Control Trust, which changed its name to the Family Planning Association in 1939. The sessions were held in premises designated for maternity and child welfare, and owned by local authorities. The FPA fought a fierce battle to get the importance of family planning recognised, but although the NHS had been introduced in 1948 it did not take over the running of the service until twenty-six years later. Doctors were surprisingly uninterested in this vital aspect of health.

From the beginning, owing to the tripartite nature of the NHS, there was a varying degree of rivalry between community services and general practice. I had been lucky to experience friendly relationships on the Isle of Wight, fostered by the medical officer of health. But in other places there was a feeling that clinic doctors were busybodies who created unnecessary extra work for the GP. Certainly, for many years, working for the FPA and in the community service I was not allowed to prescribe anything other than contraceptives. Any patient who was ill had to be referred back to their ‘own’ doctor. This rivalry was not helped when GPs finally agreed to provide family planning in 1975 and were paid on an item for service basis – although they refused to become a source of free condoms.

One GP complained that too many women doctors were being lost to medicine by doing nothing but working in FP clinics, that they had opted out of their duty to heal the sick. In our hearts some
of us might have agreed with him, for the choice was, to a degree, a soft option. The volume of knowledge required was manageable; we were spared the responsibility of caring for sick people. Yet I was meeting doctors who had spent their lives in the field and who filled me with awe-struck admiration for their dedication and their understanding of human suffering.

In respect to younger patients the FPA was slow to provide a much-needed service. Until four years before they handed the service over to the NHS the clinics were supposed to ask for proof of marriage or intended marriage. The provision for younger people had been left to the discretion of local FPA committees, some not very liberal. Because of their lack of total commitment, special centres to cater for the needs of the young were opened. These included the 408 centre in Sheffield and a network of Brook clinics. I was sad not to have had the opportunity to do more than occasional sessions with these organisations for I enjoyed the young patients who came to general sessions and believed strongly in the work.

Intercourse with a girl under 16 years old is illegal. Guidelines about protecting her from the results of that action have gone through various forms, influenced by the campaigns by high-profile parents, who have tried to insist that they are always informed when an underage person seeks help. The medical decision depends on assessing whether the young person is mature enough to understand what she is doing. Usually this is not difficult. One has to talk about the possibility of involving the parent, but if a girl says she needs contraception she probably does – although one youngster stays in my mind.

A mother brought her thirteen-year-old daughter and demanded I put her on the pill. She had been discovered having sex with a boy on a school outing. After some talk, the mother allowed me to see the girl alone. I got the impression that she had been looking for attention and although compliant had not fully realised what was happening. She told me how her parents favoured her sister and she felt neglected at home. She did not want to take the pill, as she had no intention of having sex again for a long time. When invited back
into the room, her mother reluctantly agreed to follow her wishes but it was clear that I would be blamed if her daughter did become pregnant. We discussed ways in which the girl might feel more appreciated and she was thrilled when her mother offered to redecorate her bedroom. At the time we had coffee-making equipment in the clinic where one of the nurses was particularly interested in adolescent children. We encouraged the girl to drop in for coffee and a chat whenever she wanted. A funny sort of contraception, not easy to audit or build into a cash-strapped service. But the result was that she did not need to take the pill for several years and she did not get pregnant.

During my time in Wakefield I gained the FPA certificate to become a training doctor. The organisation continued to offer training to doctors under the auspices of the Joint Committee on Contraception, which was formed in 1973 by the College of Obstetricians and Gynaecologists together with the College of General Practitioners. This joint committee provided reaccreditation for me in 1979 and again in 1984. Theoretical courses were followed by practical experience in designated clinics. When training, a doctor first sat in with a training doctor to observe, then ran the clinic under supervision. A male trainee could cause some difficulty if a patient had chosen to come to the clinic specifically to see a woman. Sympathetic explanation by the reception staff, who worked in a voluntary capacity until the NHS took over, helped most patients accept the presence of a trainee whatever their sex. I enjoyed training and discovered a latent love of teaching, perhaps inherited from my grandmother who started the family school in Swanage.

Within the branches of the FPA, the doctors and nurses had established clinical groups that met two or three times a year for lectures and mutual support. With the hand-over of clinics to the health authorities some doctors felt the need of a national association of doctors working in the field. At that time I was attending the Northern Inter-branch Group in Yorkshire chaired by Dr Kay Reid, who believed that we had to join forces with other groups to maintain standards of practice and training. I supported her idea.

Before the merger took place Ralph was appointed Governor of Maidstone prison and we moved to Kent. I found family planning work in the area with no difficulty and joined the family planning doctors’ group in central London. To my disgust they showed little interest in joining with others groups, implying that as they were already the centre of the family planning world they had no need for any expansion. This discussion took place at my first meeting and I was too cowardly to speak up for my provincial colleagues. Afterwards I was so ashamed that I wrote to Kay offering to do anything I could to help form the national group, claiming prowess at licking stamps. The result was that I was asked to serve on the steering committee and later elected to the first council. We decided to produce a newsletter and to my surprise I found my name on the first edition, as joint editor with Michael Smith. I would never have volunteered for such a job, considering my inability to spell an insuperable barrier. But I was not consulted and in the event that offer to lick stamps was another small incident that tumbled me into unexpected opportunities.

The clinical material available for the first few issues of the newsletter was very scanty. Our members were too busy with work and their own families to be interested in promoting their careers by publishing papers. I found myself trying to turn scrappy handwritten observations into articles that looked professional. The important contraceptive research trials, involving large numbers in multiple clinics, were organised by well-known academic figures such as Martin Vessey and were published in established journals. However, in a comparable way to the developments in the College of General Practitioners, we felt there was scope for study and discussion of practice by those doing the clinical work. Above all, I wanted a journal that raised the profile of family planning within the medical profession.

To my surprise I discovered that I enjoyed trying to sort out ideas, and took pleasure in working with one, or at the most two, other people, exchanging views and sparking impressions off each other. I became passionate about the work but Mike could always bring me
down to earth in unexpected ways – as when he had to abandon what I considered an important pre-Christmas telephone conversation to catch the live goose running free in his office.

We soon formed an editorial committee and my friend Margaret Corbett acted as unpaid statistician. Her main interest had been in dermatology, but she was developing her knowledge of medical statistics and worked hard, in a voluntary capacity, on our articles although they were not very sophisticated. On one occasion we were flattered to be sent some work by a well-known researcher. Margaret was uneasy about the paper although she was unable to locate the problem. ‘It just feels wrong,’ was all she could say. The committee was so keen to grab what they thought would raise the prestige of the journal that they insisted we publish it. Later, the whole body of that author’s work was exposed as fraudulent.

One of the most important days in my entire medical education was provided by the BMA when they ran a course on Writing and Speaking in Medicine. One hour was devoted to the organisation of a scientific paper. The lecturer started by telling us that there were four questions to be answered by any paper. (1) Why did you start? (2) What did you do? (3) What did you find? (4) What does it mean?

He explained that the abstract should summarise the reply to the last three questions. The first question must be answered in the introduction by a brief review of previous work and the gaps that the present paper hoped to fill. The answers to the second and third questions were fairly clear and should come under methods and materials or some similar title, followed by results. The conclusion was then left for interpreting the results, pointing out the limitations and suggesting possible follow-up studies. Since then the headings have become more direct, starting with ‘study question’ then ‘summary answer’ and ‘what this paper adds’.

For me, a non-academic, a formalised method of approaching a medical paper, either to write it or read it, was revelatory and gave me a foundation with which to try and make the newsletter, which became for a time the
British Journal of Family Planning
, look respectable. The process was a long, uphill slog.

During this time Ralph and I spent a holiday in Malaysia. We stayed in Penang where I had arranged to meet the local family planning advisor. She asked me to join a meeting being held in Kuala Lumpur the next weekend. By then we would be in Singapore, but I discovered a flight, newly scheduled for business travellers, which would take me there and back in a day. I passed up a chance to drink at the famous Raffles hotel (taken up with Heather Montford years later) in order to make the trip.

Sixteen highly experienced female community workers, non-medical leaders of family planning services in the thirteen states and three federal territories of Malaysia, had gathered for a lecture on, of all things, sexual problems in obstetrics and gynaecology. At the last moment the consultant could not get away so he sent a junior doctor in his place. I was sorry for this embarrassed young man and did what I could to relieve his confusion. At the end we all had lunch together in a café where we ate Nasi Goreng. The conversation was exclusively about female circumcision (now known as female genital mutilation, or FGM). The lecturer bolted his food and left, saying he would collect me later and take me to the hospital.

The assembled organisers represented all three races and several religions and sects. Some had themselves been subjected to various degrees of the mutilating operation – and did not condemn it entirely. For one it had consisted of no more than slight shortening of the outer lips of the vagina, a compromise that satisfied tradition without damaging her chances for a happy sexual life and child-bearing. Others saw it as the abusive and often severely damaging procedure we know it can be. One of my new friends had grown up excited by the expectation of the symbolic act, marked in my own culture by a girl’s first lipstick or bra.

After the privilege of being included in these intimate discussions, the lecturer led me through the O and G department, where women in labour sat on chairs as they waited patiently for a delivery bed to become vacant. Once a woman had given birth, and the placenta had been expelled, she was moved back onto a chair with her baby, to wait for a brief spell before being checked and sent home.

I was taken onto the roof where a tutorial was in full swing. Despite the heat, the consultant, who had trained in England, grilled his junior staff without mercy. I had retained little of my undergraduate knowledge of O and G and was completely out of my depth. Thank goodness he didn’t ask me any questions. I was impressed by his determination to make the most of his limited resources and his imposition of the most rigorous academic standards.

Under my arm I had a copy of our FP journal, carried in the hope that they might take out a subscription. I approached the senior registrar with the suggestion. His first and only question was, ‘Is it listed in
Index Medicus?
’ At that time, despite much effort on my part, it was not. He turned away in disgust.

Eventually, in the hands of my friend and talented successor, Elizabeth Forsythe, the journal was included, both in
Index Medicus
and other approved lists of medical journals. After several years of intensive work a Faculty of Family Planning was established at the College of Obstetrics and Gynaecology and the journal took its present name –
Journal of Family Planning and Reproductive Healthcare
. The speciality had arrived.

In addition to training doctors and nurses in contraceptive methods, the FPA ran a variety of courses on subjects such as abortion and vasectomy counselling. The abortion act passed in 1967 provides specific situations in which a woman can obtain a legal termination of pregnancy. The most important provision includes ‘. . . the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman or any existing children of her family.’ Two doctors had to be satisfied that the criteria were met before signing a form.