Chapter 28

Chapter 28

UK 2001-2002
I decided to explore the possibility of doing locum work in the UK and contacted my friends in the country for advice. They referred me to a few employment agencies. I was taken aback; I had never heard of such enterprises. UK had a tradition of hiring locums for Doctors going on vacations. But one used to get them through personal contacts or from the classified advertisements in the British Medical Journal. I was to discover that Locum agencies had mushroomed there as IME companies had in the USA and was soon inundated with offers. They wanted me right away, but I had to renew my registration with the General Medical Council in London. That went through with out any trouble, though it took several weeks .
. I eventually accepted a Locum Consultant position in a town called South Shields near New Castle in the north of England. It was not a good experience. The department had seen better days; it was terribly disorganized and a lot of infighting went on. Except for the department head, the other four consultants including myself were all locums. The lone substantive consultant was the head of the department. He was from an African country. All others were from India. The latter conducted an unrelenting campaign to undermine the former Indians would rather not have a Pakistani either Prejudices die-hard. I found the milieu particularly uncomfortable. A long-term sub-consultant was terribly disappointed that he had not been offered the job I had.
It was a drab town with derelict housing, high crime and drug addiction rate, rampant alcoholism-all marks of a society in decay. Work was not heavy and I had time on my hands. There was nothing much to do. With out a car it was difficult to get out of the town as one had to take the infrequent train to Newcastle wait there for a long time to get any where. One of my classmates from the medical college was in the area and I visited him once and he called on me a few times.
I missed home terribly. What made me feel worse was that I had not been able to attend the High School graduation of my daughter Sana who I am emotionally very close to. She had been by far the best student in my family for a long time. I have inherited high regard for academic achievement from my mother and Nana. I was, however, able to fly back for a weekend for her graduation party.
Right after the party I flew back to England and took another locum position in a hospital near Manchester. This was to turn out to be even less satisfactory than the first one in many ways. The locum agency had sent me there as a locum consultant. The hospital told me that they desperately needed a man in the number two spot. They will pay me at the consultant rate. I reluctantly agreed, but asked them to find a replacement quickly.
At this point I decided to take a break and returned to Bath. It was the first time in many years that I had leisure. I read, worked out side and felt at peace with myself. But the state did not last long. I had an offer of a long-term locum in a suburb of Glasgow in Scotland. I had never worked there before. In fact my only excursion furthest north, except for a few days when I had gone to Edinburgh in late 1967 to take the final FRCS examination, had been to Liverpool area. I left for the UK again in September 2001
It was the best Locum I was to have though it involved working in two hospitals, traveling to clinics in outlying every week and a stay over night in a motel twice a month. But the distances were not great; about seventy miles was the furthest clinic. The roads went through the valleys and hills. It was very picturesque in the summer and dismally bleak in the winter. About the only problem I had was with my driving habits and skills. British motorists, even the older ones, tend to drive fast and take corners at higher speeds than I was used to. The car I had rented had a small engine with very slow pick up, so I was rather slow off the mark. Mercifully and unlike American (and Pakistani ) drivers they would not blow the horn at the slightest pretext, though I must say the temptation must have been strong.
. They had given me a room in a subsidiary hospital about twenty miles from the main hospital. About one third of the work was in the smaller hospital. One clinic was about seventy miles in a pretty as picture sea resort called Oban. Another clinic was fifty miles away. A third was in a village a few miles from the smaller hospital. I had two operating sessions a week. Out patient work averaged three to four session and that together with a conference and two clinical rounds made up all the work. In addition I was on call one week in six , but during my five months in the region I was called only once at night. If I am giving an impression that I worked hard, I am misleading the reader. The work stated at 9.00 am and ended at 5.00 pm, with an hour break for lunch All together I worked about twenty four hours a week, and was paid about 10,000.00 pounds a month for doing so. This would be equivalent to about $ 19,500 in the USA, and it was net income, as I had no office, insurance or malpractice expenses.
Scottish people are very friendly. I did have a problem though with their accent and it took a while for me to get the hang of it. I still recall that if you thanked them for a service, they would say what sounded to me like “no botho”. It translated as “no bother”. They do drink a lot in the country. Once during a clinical conference I made a remark on the signs of advanced loss of calcium on an x-ray of a relatively young patient. One of my colleagues said it was alcoholic osteoporosis .
I had an easy time in the hospital. They had assigned a Pakistani assistant to me. The man had had years of training and several more years as a first assistant. He could perform nearly all procedures but lacked confidence. He had never performed a total knee replacement and made a special request that I put him through the steps. I did. He was very appreciative.
I worked there for about five months. But living alone at my age was too stressful. I did try to organize communal cooking in the hospitals I worked in. Many members of junior staff would join me in preparing food and eating together. We would make “family” shopping trips, and go on picnics. I even conducted seminars on current affairs. I met many young physicians some of whom became very close to me. After we had cooked, eaten and shopped together for a while, one lady doctor Zakia by name, asked me if she could call me Abbu (Daddy). I was a little taken aback. She explained that she had lost her father when she was quite young. I was touched and agreed readily. She was jealous of another “daughter”. The doctor in question was from Myanmar (Burma). My Pakistani daughter would break out in Urdu as soon she saw the Burmese girl. The latter would be immediately put off and often leave. Zakia was a very enterprising girl. She worked as a regular trainee, took up locum work over weekend and saved enough to buy an apartment in Karachi-an unheard of accomplishment for a doctor not in private practice. She eventually returned to Pakistan. I met her in Karachi during my last visit.

In early 2002 I did two locums, one in the south of London near where Eram was born. But I did not feel like visiting the house we lived in alone. The other locum was in the very hospital I had worked in Wales in 1967. I had been friendly with a Welsh girl, who had actually indicated that she would like to accompany me to the USA. But I was at the time involved in my roller coaster relations with my ex. I sent a message to her through one of the patients in the clinic. She did not respond. I did not pursue and consoled myself with the thought that perhaps she had not gotten the word. I also renewed acquaintance with some of my old co-workers and friends. But I had to, perforce, change the hospital every few weeks and start anew. Finally it got to be too much.
In 2001 I was to discover many radical changes in the health service. Consultant was no longer the demi-god he had been. Long gone were the days when she/he ruled the roost. In my training days the consultant had his own unit-Hospital beds, nursing and trainee staff, and compliant theatre (operating room-OR) staff. No one dare admit a patient on his ward with out his specific say so. He made rounds with a full complement of junior Doctors, Nursing sister (head nurse) and a representative from physiotherapy department (PT). No one dare protest that surgical list had exceeded the allotted time, or postpone a case in the event. He ordered and all obeyed. Now layers of administrators had been added who could cancel a Surgeons operating list or admit a patient in his ward without his permission. In my earlier time in the country, this would have been an unthinkable and unforgivable deviation. The Consultant would throw a fit. Now routine surgery stopped at 4.30 pm. As the cut-off time approached nurses would openly grumble and ask that cases be postponed to the next list, which would naturally have no room. Administrators would get in the act and “advise” the consultant.
The whole ambience has changed. The trust between patients and Doctors, which both used to take pride in, was a thing of the past. Patients would often make a complaint to their member of the Parliament against their Doctor or the Hospital. It would be a bonanza for the administrative staff; they relished the time consuming enquiry and the opportunity to harass medical staff. Malpractice suits, nearly unheard of during my earlier service in the country, had become fairly common, though still far behind the rate in the USA. I remember in 1965 I paid 30.00 pounds per year for such insurance premium. The rate had gone up to 5000.00 pounds per year. (The comparative rate in the USA would be the equivalent of 50,000.00 pounds per year).
Quality of service had declined too. Waiting lists were horrendously long; one has to wait for a year before getting a knee or a hip replaced. The waiting period used to be longer before the Parliament mandated a few years before 2001 that it had to be kept under 12 months. Consultants were consequently very hesitant in putting patients on the waiting lists and tried to buy time with injections, Physical Therapy and palliative procedures . They did not work the hours my consultants used to. I say this with confidence as a first hand experience that in 2001 and 2002 consultants worked, on an average, 20 to 24 hours a week. General Practitioners used to take their own calls in rotation with their partners. Not now; come six pm calls were transferred to an emergency service, as would all the calls be from six pm Friday to 8 am on Monday. New regulation did provide welcome relief to junior staff who had their hours of work fixed to, I think it was 44 hours a week, so that they would get one and a half day off every week, an unheard of luxury in my training days.
. The deterioration was the direct result of the cost cutting, euphemistically called re-structuring, initiated by Margaret Thatcher as a part of her campaign to whittle away at social services . The Health service was starved of funds, partitioned into regions, and the heads of the regions was penalized if they could not scale their budgets down. The pattern was much like that of HMO’s in the USA. Family practitioners in the UK (called General practitioner GP) could haggle with hospitals on the cost of hospitalization. Many in metropolitan areas resorted to such outlandish schemes as bussing their patients to distant hospitals. One enterprising London GP sent his patients to Bristol, about a hundred miles away. Except for emergency treatment, the patients had to wait for long periods for routine treatment.
In the USA surgeons and patients resort to reconstructive surgery much too soon. Like everything else private medical practice is also market driven. Results of early surgery are comparatively less favorable, as the doctors and patients do not put as much effort in pre and postoperative care. Further the results are subjectively much better if the symptoms are severe and the patient demands the procedure; the relief is so great that they ignore minor postoperative problems. I, used to American practice, put "too" many patients on the list. Other consultants with typical British understatement asked if I was not being too generous.
There were several other problems with health service. Drugs were no longer free. With loss of prestige and control over their work, physicians started taking less interest in their patients. Introduction of American style health insurance, private clinical care virtually unknown out side of London, where it was based essentially on rich Arabs, became a favored choice for those who could afford it. NHS patients suffered. Doctors left the country for Australia, New Zealand, Canada and the USA in droves, leaving wide gaps in the ranks. NHS was hard pressed to replace them. They had to pay more to temporary employees than they did to regular employees. Employment agencies took a hefty cut. Substantive consultants worked as locums during their vacations. In the sixties, a consultant would be laughed out of his community if he did that. With no stake in their place of work, locums did the minimum possible adding to the problems of the service.
The Blair neo-labor had picked up from where Thatcher left off. One of my friends wistfully lamented that Blair was far to the right of Heath, one of the more notable conservative post WWII British Prime Ministers. The only part of the service they could not mess with was the Emergency Department. Patients, the serious ones at any rate, were handled expeditiously and with skill.
I had come across an advertisement in the British Medical Journal that examiners for disability determination were urgently needed. This was right up my alley, or so I thought at the time. I was getting tired of packing my bags every few weeks and made a telephone call. I was given an appointment to meet the director. She was very impressed by the fact that I had performed IMEs in the USA . The business of disability examinations had been out sourced to an American firm. She was nearly apologetic that I would have to undergo didactic and on hands training and gave me dates for the next course of lectures.
My fellow trainees in the course, about a dozen belonged to the fields of family practice, psychiatry and one rehabilitation physician. I was the only orthopedic surgeon. During the lectures I was to discover that I would be expected to assess the claimant not only for physical deficits but also examine the psychiatric, pulmonary, heart, kidney, circulatory and all other body systems. I told the instructors that I only had Orthopedic training, had worked in General Surgery thirty-five years ago and had had no exposure to Internal Medicine or Psychiatry at all. Did they expect I would learn all that in all of one week! They told me not to worry. I would not have to pass any judgment and would only have to follow a book of guidelines; all I was required to do would be to report my findings. A lay adjustor who had no clinical background, training or knowledge would make assessment.
The British are true artists in innovation. If they had claimants examined by specialists, as is the practice in the USA, they would have to pay a lot more fees. I did that work for a few months.
I had opted for the work because I would not have to move again and again. I worked for a few weeks in Luton, a city forty miles from London. The organization then found a slot for me near Liverpool. I was lucky to find an old-fashioned bed and breakfast hotel. The land lady granted me cooking privileges, the run of the dining and TV rooms, and took me shopping as I did not have a car. I worked long hours six days a week, and pitched in if the firm wanted me to work on Sundays too. The other doctors did not like it. I was setting a bad example. They were jealous too of the amount of money I made. But I had little else were no longer free and would have been driven to distraction otherwise. The work was boring and dissatisfying. In spite of trying to keep busy I found time hanging heavy on my hands. I also felt out of my depth in deciding on the parameters of heart failure or schizophrenia. I finally quit, to the mutual relief of self and the agency.
Disability determination work exposed me to deterioration of social services and decline of living standards in the country. Contrast to the conditions in the sixties, which I have described earlier, could not be greater. Gone were the social support systems, which helped the unemployed, and the sick live in a fair degree of comfort and had been an incentive to quick rehabilitation. Now people lived in squalor and had lost self-respect.
Worst affected perhaps was education. The British had taken justifiable pride in their egalitarian attitude towards higher education. If your academic standards were good enough, you could go to any institute of higher learning-Oxford, Cambridge, various imperial colleges and that icon of liberal thought, the London School of Economics.
Unemployment and poverty figures reached levels described by Charles Dickens and Somerset Maugham. With the welfare system gutted by Thatcher and Blair, people were forced into crime. Even the sick workers were victimized. Up to the initial Thatcher years, employers dare not question a doctor’s note for thirteen weeks. Now they would be sent to disability determination agencies much sooner. Racial discrimination had been episodic. Now it had become systemic. Riots broke out in many cities in the north of the country in 2001. Tension simmers just under the surface all the time. Cities with large immigrant population like Birmingham, Bradford, South Hall, Leicester and many others remain at the point of explosion. Tolerance has been thrown over board. Even love life has taken a beating. The number of mixed couples, on the rise through the sixties and the seventies, is on a downslide.
Rich have become richer. You could get not a reservation in even a moderately fashionable restaurant or in the theatre for weeks. London was awash with Rolls Royces, Bentleys, Aston Martins, Jaguars, BMWs and Mercedes. During the sixties, in non rush hours, I could drive from London city center to Luton forty miles away in fifty minutes. Now it takes over two hours. The number of cars has increased so much that the famed motorways where once one could drive as fast as the car could, looked like one vast parking lot in rush hours. Real estate in moderately good areas has gone beyond the reach of all but the very affluent. Business is booming. So is mental illness and the charm of messianic teaching. The society has become a fertile ground for production of extremists and suicide bombers.
Poor have become poorer. I visited slums on the out skirts of many big cities. I could compare them favorably, in piles of garbage and stench, with the poorer sections of Karachi. Indian curry, much cheaper than the native food, has overtaken all British dishes in popularity. That is not because the natives have suddenly taken to spicy food. It is cheaper. I had tried hospital work and disability business. I made good money in both. I visited home in Bath several times a year. But the stress was too much. Tired of the life of an itinerant doctor, I decided to try to reconcile myself with retirement and returned to Bath in January 2003.