Friday, 3 October 2014

My first Locum

This is a variation of an excerpt in my autobiography Memoirs of a Medical Maverick, Liberties Press, Dublin, 2010

I spent four years in London training in cardiology. I virtually had no income but I used to work for some of the Irish general practitioners, usually night clinics for which I was paid one and one half guineas. My experience of general practice also extended to one period of three weeks in Ireland. I had a month in London without any commitments in the summer of 1949. I thought I might add to my depleted finances by doing a locum in general practice in Ireland, while at the same time making welcome contact with home and the family. I wrote to Tom Prendiville, my brother in law and county physician in the south riding of County Tipperary, asking him to make enquiries about holiday locums and, in doing so, I emphasised the importance of finding a lucrative one which would allow me to live in the luxury to which I aspired. He was good enough to respond by finding me a holiday locum in the village of Killenaule in the heart of the Tipperary hinterland, and about equidistant from Fethard in the south, Cashel in the west, Urlingford in the north and Ballingarry in the east.
Cormack's in more recent times.

I should have known that Tom was too unworldly and detached from the realities of life to understand the circumstances of a poverty stricken young doctor and to occupy himself with such mundane matters as money. I was paid seven pounds a week for my services to the dispensary or publicly assisted patients. This was exactly what I paid for my weekly board and lodging at Cormack's Hotel, a small and modest hostelry and pub on the rather unkempt, narrow, long and winding main street of the village. However, I was entitled to keep any private fees I might earn.

The principal whose locum I was doing had recently retired from the army after the Emergency and apparently had little experience or knowledge of general practice. It was government policy at the time to appoint those doctors who had joined the army during the Emergency to a dispensary to ensure that they were not disadvantaged by their courage and patriotism in playing a part in the defence of their country. The doctor appointed to Killenaule failed to gain the confidence of the local community, apparently because of an error of prognosis soon after his arrival, when a young girl who was complaining of a severe headache was not hospitalised immediately. She died soon afterwards from a subarachnoid hemorrhage.

The doctor's practice was largely confined to his dispensary patients. Private patients were attending doctors in the surrounding towns and villages. He had no private practice. I had only one, at least for the first two weeks of my three week stay. It was the duty of dispensary doctors at the time to provide medicines for their public patients, but I found little evidence of these in the dispensary building, where the shelves were mostly stacked with DDT powder. This chemical had been discovered during the recent world war and was being freely distributed by the authorities to control the insects and other fauna which were widespread among homes and people at the time. My dispensary duties were largely confined to handing out packets of DDT powder to those who arrived at the rather primitive and mean building which housed the dispensary. I soon found that even the dispensary patients were attending doctors in a private capacity in the surrounding areas.

I did, however, have a private patient during my first week. I was approached one day in the main street by a tall, gaunt, cadaverous creature with a shifty look and with an old cap drawn down over his eyes. Furtively looking around the street, he asked me of I was the new doctor from London. He then told me that he was getting very deaf and could I do something to help him. I told him to accompany me to the surgery where I could examine him. Although I was perfectly aware of the diagnosis as soon as I had a superficial look at him, because I could see the wax protruding from his two ears, I made a little fuss about examining each ear with my auriscope, and then saying

"You've got wax in your ears. It's blocking the ear passages. I'll have to syringe them out. That should put things right."
"And how much will that cost, doctor?" says he.

Never having discussed or asked for a fee before, I was immediately thrown into a state of panic, but I managed to blurt out  "a pound" and then I made the first commercial mistake of my career, although by no means my last. I added "ten shillings an ear!" 

He said "Well, doctor, I'll have to think about it" and out he went to the street, no doubt to commune with his long dead mother or his favourite saint. Ten minutes later, during which I waited with feverish anticipation, he returned. "I'll let you do one ear" he said, "and if that's better, sure I'll let you do the other". So I syringed out one ear, and had my first experience of an ethical dilemma. Should I do the other ear? I decided, no, but I was left with a slightly uneasy feeling that Hippocrates might have disapproved.

For the next fifteen or sixteen days, I met him daily on the main street. Seeing me, he would if necessary cross to the other side, pull the cap down further over his eyes, and pass me by, no doubt certain that I would not recognise him. I never heard what happened to his second ear, but he will remain for ever in my memory as the first patient to pay me a private fee.

Incidentally, and to leave the subject of Killenaule for a moment, my first fee when I commenced consultation practice was earned in October 1950, just after I had returned to St. Vincent's Hospital. I was sharing the first floor return room at Bill Doolin's house at 2 Fitzwilliam Square with Oliver McCullen. A farmer arrived in from Tipperary and as he was leaving, he said to me "I'm afraid I would not have enough to pay you. Would it be alright if you sent me the bill?" I said "of course", being relieved that I did not have to bring up such an embarrassing subject. I saw him down the stairs and just as he got to the door, he said " Sure maybe I do have enough to pay you. What's your fee?"  I blurted out "Three guineas", being fearful that he would collapse with dismay and shock. "Ah, sure doctor, I have that and ten times over" and with that he takes out a huge bundle of notes and hands me three little green backs. I could detect that his opinion of me as an eminent Dublin specialist plummeted on the spot!

There was a tradition in those early years of giving your first fee to your mother. I might have done so if my financial circumstances were less precarious, and if the rumpled and dirty old red ten shilling note which I earned during my first week in Killenaule were more presentable.

In my second week in Killenaule I earned five pounds, although to say that I earned it is an exaggeration. It was customary in Ireland at that time for the doctor attending a confinement to receive a five pound note from the mother after the delivery was completed, whether she was a dispensary patient or not. I got an urgent call to attend a woman in a farm house some distance away from the village. When I arrived on my bicycle, I found that the woman had had her baby and that the handywoman present had supervised the entire event, so that the patient was comfortable and well settled down by the time I arrived. I went through the motions of feeling her pulse, pronounced her well, complimented the midwife on the successful outcome, and was about to leave the bedside when the patient took a five pound note out from under the pillow and handed it to me. While I was careful enough to take the money, I felt somewhat embarrassed accepting such a munificent fee when the midwife had done the work, and no doubt was paid a pittance for her trouble. I was to learn later that many of the fees received by doctors are at least partly earned by their nursing colleagues.

By the beginning of my third week the word had got around that there was a new doctor from London in the village. I collected twenty five pounds in fees during this last week, a quite respectable sum at that time. In my third week I also acquired a chauffeuse with a brand new land rover. My driver came down from Thurles every morning to take me on my calls. She was a Dwan from Thurles whose father owned a mineral water factory. Before Miss Dwan arrived on the scene, I had done my calls outside the village on the schoolmaster's bicycle. I felt a new sense of dignity and importance after her arrival, and these feelings must have been conveyed to my patients, because I found myself almost invariably invited to take a glass of wine after each domiciliary visit. The wine was by tradition Sandeman's port. It was probably the equivalent of the priest's bottle, which was a feature in many country homes in Ireland and which was invariably a glass of port or Irish whiskey.

When I was leaving Killenaule I was satisfied that a useful living could be made there in general practice, although whether success depended on having a handsome and comely maiden from Thurles as a chauffeuse is a moot point.

Cormack's Hotel is still extant, I believe, I was last there during the general election campaign of 1957 when a crowd of us used to go down to Tipperary every weekend to canvass for dad. It was to be his last election, so that a great cohort of Dublin people who were friendly with the family took part in the exercise, some of whom were not even supporters of his party. I am not sure that we did him any favour by participating in the campaign, although he was successful in being elected. I know that the locals were rather bemused by the arrival of this large body of young middle class professional types whom one householder contemptuously called college boys. I arrived at this man’s doorway with Donal O'Sullivan. I had a bow tie, a yellow tweed waistcoat designed and made by my sister Neilli, and a pair of immaculately creased flannels. When he opened the door, he stared at the two of us for a moment. After this unnatural pause, he turned and shouted to his wife who was somewhere at the back of the house "Mary, will ye come up and have a look at the college boys!"

There were a number of other bizarre confrontations between the city slickers and the country people which cannot have helped in the cause we were serving, and which was a reminder of the sharp social and cultural divide between the urban and rural populations at the time

We used to gather at Cormack's Hotel in Killenaule on the Sunday evenings after the
Killenaule in years gone by.
 weekend campaign was completed. We had a supper of sandwiches and Guinness on our first Sunday there. It was a very wet stormy night and, because Killenaule was off the beaten track, enquiries were made about the best way to Urlingford and the main Cork-Dublin road. We had a cavalcade of five or six cars. I explained that I had done a locum there in 1949 and that I knew the country intimately. I would lead the cavalcade to Urlingford by the safest and shortest route.

We set out about midnight having eaten and indulged adequately in the local black brew. We were a happy lot and were no restrictions on either quality or quantity of alcohol at that time. It was frightfully wet and stormy. I drove for some eight or ten miles, and after a while I began to feel a little uncertain of my bearings, particularly as driving conditions were so very bad. However, eventually we arrived at the outskirts of a village. It had a vaguely familiar look about it but it was not until I arrived at the centre of the main street that I realised that we were back in Killenaule! At first I thought in my panic that I would drive through without comment, hoping that my mistake might remain undetected in the storm, but on second thoughts I was sensible enough to realise that such a subterfuge would only add to my troubles and my embarrassment. This, more than any other event in my life, was to tarnish my reputation with family and friends for years to come. Subsequently, if I ever expressed a strong opinion about any subject in their presence, I would be reminded of my intimate knowledge of the topography of the County Tipperary.

Cormack's Hotel was a small commercial hotel run by Mrs Cormack who was a widow, and her son, Cormac, who attended mostly to the bar. They were a delightful and hospitable pair. Like the country people I used to know during my childhood in Kerry and later in County Wexford, they were the salt of the earth, honest, hardworking, uncomplaining, full of humour and humanity, generous, and entirely non-acquisitive. Some of my time was spent cycling around the countryside but many of my evenings were spent in the bar drinking an occasional glass of porter and talking to the locals, and particularly to Cormac and to a Kerryman by the name of O'Shea, who was resident in the Hotel and who was the local schoolteacher. Cormac was a raconteur of some merit, and used keep us amused by his stories, but O'Shea was a mine of information about the county and about the social background and people of Killenaule. He was entirely uninhibited in his comments about the local scene, and had, thanks to his many years as a national school teacher there, an intimate insight into the circumstances and customs of the people.

Killenaule church in more recent times.
Killenaule was not the worst village I had known in Ireland, but even in the context of those times, it was unkempt, featureless and lacking in architectural merit or amenities. On the Cashel road there had been about a dozen cottages, some of which, although occupied until recently, were semi derelict or in almost total ruin. On the other side of the village on the Ballingarry road there were six modern two storey houses. 

Apparently the occupants of the worst of the cottages had been moved to the new houses which had been built at the beginning of the war. This was an error of judgement on the part of the County Council, for these families were the most irresponsible and improvident, and therefore the least house proud. By 1949 the new houses were in a sad dilapidated state, with the gardens unkempt and full of rubbish, the boundaries broken and a general air of neglect and untidiness. According to O'Shea the baths were used for storage and there was hardly one stick of decent furniture in any of the houses. And, not surprisingly, there were many unkempt children to be seen. Louise and I passed through Killenaule two years ago visiting a book fair. I can assure you that much has changed for the better. It is a reminder of the huge benefits we in Ireland have received by the Tidy Towns campaign

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