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Medical Truants

Posted by Dr No on 09 January 2011

doctor4.jpgDr No has Boots down as an otorhinolaryngologist - an ear nose & throat surgeon, but then the Greek always sounds better in the plush of private practice. These are the chaps who mount CDs on their foreheads, the better to peer into your orifices. Quite why the tonsil baggers need to mount a CD on their forehead to see what they are doing baffles Dr No. Gynaecologists seem to manage very well, without resorting to shining Abba’s Greatest Hits up the old hoo ha.

One might suppose all that peering through CDs might narrow both mind and vision, but Boots has clearly escaped a constricting fate. He has cast his surgical presence wide on the Borsetshire stage; and few indeed are the pies that have escaped the Boots finger. He is very bright, reads widely, and has the natural gift of synthesis to Boot. And so it is that when we come to survey his blog, we find well crafted posts, always finely written, invariably most interesting.

So it was with mild surprise that Dr No saw that Boots had, in a recent post, linked Dr No to ‘medical truancy', which he described as one of ‘Dr No’s terms’ - despite the fact Dr No has made it quite clear that it is not one of his. A hazy sense of Boots being up in the air, possibly even on the other foot, drifted over Dr No. Not only does he consider the term not his, he actively dislikes it, and so feels a natural but gentle urge to put the record straight. And, happily, doing so provides an ideal opportunity for Dr No to, as we are wont to say these days, deliver on an earlier remark of his that ‘[medical] truants are a post for another day’.

The reason Dr No dislikes the term medical truant is because it carries an overlay of disapprobation. Boots himself in his post has medical truancy holding hands with ‘Lack of Moral Fibre’. The medical truant is tainted as a coward, a weakling unable to stand the heat in the kitchen – or perhaps even worse – a bunker off, a skiver. Now: how right and fair is it to tar a doctor without a practice with these harsh brushes?

The OED defines a truant as ‘a lazy, idle person; esp. a child who absents himself from school without leave; hence fig., one who wanders from an appointed place or neglects his duty or business’. Laziness, idleness, absenteeism; even - horror of horrors! - neglect of duty: a full house of Old Testament fury to be flung on the heads of those who truant! And, on the face of it, we cannot deny that the doctor without practice is absent from the profession, and so, it would seem, is a truant.

But, if we care to remove ourselves from the moral high ground, and look more closely at the meaning of truancy, we see that it has its roots in obligation: obligation to attend school, an appointed place, or to one’s duty; and truancy is the act of neglecting these obligations. And so it is that, in the absence of obligation, there can be no truancy.

No such obligation can fall on the involuntarily unemployed, for no one has an obligation to attend work that they cannot get. These indeed are the lost souls of the lost tribes, medical exiles, condemned to long for a lost profession. To taint these tormented beings with the tar of truancy is indeed a harsh and baseless cruelty.

But what about those who have chosen to exclude themselves from the profession, perhaps to seek a sunnier prospect, or because they have passed their private Rhett Butler Moment, and now know that the lover that once called to them so strongly is today no longer for them? Have they, in exercising that choice, dissolved the ties – if they ever existed – of obligation? Or could it be that those all too real ties of obligation, knotted now into harsh whips of punishment and disapproval, have now come back to haunt them?

Hacksaw and her descendents will naturally see the matter through the prism of the till. Medical students ring up a quarter of a million pound bill on the tax-payer by the time they qualify, and so, the argument goes, they have a duty, an obligation, to pay back that investment by the tax-payer, to the tax-payer, by practicing medicine.

But this argument has more holes in it than the coalition. Hacksaw herself studied chemistry, but felt under no obligation to spend all her life playing with Bunsen burners. Not all psychology graduates practice psychology, nor all art graduates paint or sculpt. No degree is a contract of obligation, a straight-jacket, to a single career. Indeed, were it so, we could happily rid ourselves of all those LLBs that litter parliament, and return them to their Dickensian cupboards, so that they too might repay in kind the expense of their degree, and their debt to society. But we do not, and equally, we cannot reasonably compel a medical graduate to follow a medical career.

The second origin of medical duty arises not in the counting halls of the banks, but on a higher plane. Doctoring, we like to believe, is a vocation, a calling, just as it is for the priesthood; and before we know it an almost divine thread of duty threads itself through the conduct of those called to these ancient and special duties. And so it is that we reserve special censure for those who have been called, and have yet rejected that call; and so too for those wayward souls who, once called, have since cut the ties of obligation, and so severed the thread. For it is distressing to discern that those on whom we may rely on in our of need may yet themselves have lost their faith

Now – be all that as it may – a second look at what is going on here reveals that these emotions, potent as they are, have their origin not in the wayward priest or doctor, but in the observer who, discomforted, responds by projecting that discomfort onto the hapless wanderer. The wanderer, unobserved, may feel the occasional pang of guilt or regret, but not necessarily so; they are more likely to breath great sighs of relief; and say to the observer: ‘the displeasure is all yours’.

‘And, frankly my dear, I don’t give a damn.’


Dear Dr No,

I am glad you enjoy my blog. I enjoy writing it for much the same reason that I enjoy teaching. I find that having to explain my thoughts to others clarifies and occasionally transforms those thoughts. Every blogger wants to be read, but there is a certain danger. Become too popular and there is too much interest in ones real identity, as well as tiresome trolls.

I apologise for falsly accusing you of creating the term Medical Truant, I shall edit when I can access my home computer, I can only very crudely edit on my smartphone, and often blog via it in quiet moments in a day.

My phrase "lacking in moral fibre" is perhaps a little obscure in it's reference. It is an RAF term used in Bomber Command during WW2. The treatment of combat fatigue in the army was far better in WW2 than WW1, both in terms of the patient and in terms of returning men successfully to combat. The exception was Bomber Command, where the term Lacking in Moral Fibre was widespread for the psychological casualties in aircrew. Whatever one thinks about the morality of the bombing campaign, Aircrew were all volunteers, and on average flew just 14 missions, with the highest casualty rate of any arm of the services. It took real courage to walk down the airstrip and board the Lancaster. I used the phrase ironically, seeing some similarities between medical truancy and combat fatigue. Irony doesn't work on the net very well, including my moniker, which is perhaps a little too insulting!

I enjoy your blog immensely, as I do the other medical bloggers even when my opinions are very different. Ours is a diverse profession, and different ideas should be aired and tested.

Best wishes

Dr Phil

Boots - Irony and the web do indeed make queer bedfellows!

Dr No came across LMF as a medical student, on his first medical firm. If the consultant - very old school - thought a patient was malingering, he would mutter sotto voce 'LMF, dear boys, LMF...' in the direction of his trailing students. I was going to expand on its meaning in my post (and had even got a link to put in) but decided most of our readers were likely to be familiar with the term, and those who weren't could always look it up for themselves. In any event, its disparaging nature is self-evident from the tone and form of the words.

PS I do you the honour of calling you Boots (as opposed to Dr Boots/Phil) on the basis that my presumption that you are in a surgical specialty is correct, and so we would not address you as 'Dr' in real life; and as it is in the real world, so be it on the web.

I did used to think Dr Phil/Boots was a surgeon (though wouldn't that make him Mr Boots?), or possibly an interventional radiologist, but something he said the other day has led me to a completely new guess. Always a fun way to waste time, trying to guess medical blogger' specialities.

PS Dr No, you have the most savage spam filter I have ever encountered!

I am old enough to remember "lack of moral fibre" from various WW2-set movies, like 633 Squadron, if memory serves.

As Dr No points out, there are many reasons to change course within, or "out of" medicine. Mrs Dr Aust was once on a speciality training scheme (pre MTAS), which she left for a variety of personal and job-related reasons. Now, though it was nothing of the kind, I guess that to some that might "play" as LMF - especially since, following one more staff-grade stint in medicine, she switched to working part time after Jr Aust was born and has done so ever since.

I was thinking of this especially last week when Mrs Dr A stayed an extra 90 min past the end of her half-day clinic (and past the time she was getting paid for, since she is a sessional employee) to make sure that the patients got sorted out.

The boundaries between medicine and surgery are increasingly blurred. Dermatologists do operating lists, cardiologists do stents, urologists treat prostates mostly medically, and interventional radiologists are bent on world domination. The distinctions between our guilds are increasingly archaic. Indeed the PMETB fossilised the CCT to specific areas, stifling the evolution of new specialities.

The difference is mostly an attitude of mind, faced with a difficult patient a physician wants to poison him, a surgeon wants to stab him!

Ironically yours,

dr phil

Dr A - sorry my spam filter is being so savage. It is supposed to be one of those clever ones, but I suppose at the end of the day expecting lines of code to be clever given all that we humans can throw at them is a bit like expecting bankers to be clever.

If, and only if, you care to detail what was rejected to me (via the contact form near the top of this page), I will look into it. Rejecting valid comments is in effect rejecting free speech, and that is most unwelcome.

I also buy your point about Boots/Mr Boots. But you will note I carefully said what I wasn't using, not what I should use! The reason it has been Boots is because, most of the time, Boots flows better than Mr Boots. It is nothing more or less than that.

Dr (or is it Mr) Boots - this blurring has indeed been going on for some time. Dr No recalls the active management of labour, a medical solution to a surgical problem. Whether we should welcome physicians wielding scalpels, and surgeons dispensing drips and pills, is another matter. Certainly each group should both know the basics of the other, but the mindset, as you observe, is fundamentally different (surgeons, for example, appreciate wounds and healing at a level and to a depth that few physicians will ever aspire too, while many surgeons never really comprehend in their heart of hearts that 'medicines' work); and any hybrid may mutate into a bit of a monster. It wasn't that long ago that psychiatrists, fancying themselves surgeons, took to poking knitting needles where they had no business doing so.

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