BMJ  2005;331:463 (20 August), doi:10.1136/bmj.331.7514.463

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PERSONAL VIEW

The finger, the foot, my bone cancer

"If you don't put your finger in it, you'll put your foot in it"—this is an odd thought to have at 4 am, when you're waiting to have operation number three for your bone cancer. At first glance it was a bit of an imposition. A male nurse was asking for my professional opinion on his mundane rectal symptoms—at 4 am. I was awake and anxious about my own operation in a few hours' time. He was supposed to be looking after me, not the other way round. I was on sick leave.

On the other hand he was one of those nurses you value: professional, polite, caring, and helpful. And I liked him. He was my age, just over 40. He had turned a blind eye to my using my mobile phone to stay in touch with my family. In return I had lent him my charger when his mobile ran flat. These things matter when you are an inpatient for three weeks.

I had been back at work since then. My brain had shrugged off the nausea and black desperation of the chemotherapy, recovered from the postoperative depression, and woken up after the exhaustion of radiotherapy. I was back on top form and probably operating better than I had ever done. I had a rapport with my bowel cancer patients that I had not really felt before. Now here was someone who was frightened and needed reassurance. I succeeded in reassuring him—it's probably piles, you need to see a specialist, get your GP to refer you under the rapid access form, you'll be seen in a couple of weeks, try Fybogel in the meantime. "Thanks," he said. "I feel better now. Do you want a cup of tea?" He went back to the nursing station.

He was supposed to be looking after me, not the other way round

"If you don't put your finger in it, you'll put your foot in it"—this colorectal surgeon's mantra that I had hammered in to my trainees was nagging at me. I couldn't bear being one of those doctors who missed things for the sake of social nicety. Every surgeon has seen the tragedy of seeing rectal cancers, now inoperable, that had been treated with haemorrhoid creams for six months by well meaning and terribly nice doctors who wouldn't dream of doing anything as unpleasant as a rectal examination. I prided myself on my persistence in invading body cavities where others feared to go. The imperforate hymen in a virginal 14 year old was discovered because I had been a particularly diligent surgical registrar. The poor girl had come to casualty four times with suspected appendicitis before I was brave enough to tentatively suggest a vaginal examination. The monthly dates of her attendance were a small clue to her haematocolpos. I had dined out on that one.

But a rectal examination on a male nurse in the middle of the night while I was a patient? Diligence gone mad. At least I would be certain he didn't have a low rectal cancer. My cancer had been missed for a few weeks, and I'll never know whether that time delay mattered. I pressed my buzzer. He came back. "I need to examine your rectum. Get some gloves, jelly, and paper, and I'll get the empty bed next to mine set up." No chaperone, no consent form, no easy explanation if someone saw us. And there it was: a rectal cancer. At 4 am.

I know how people like me prefer to get bad news, because I've been there: straight from the hip. Solutions, possibilities, worst case scenarios, best case scenarios, a plan of action. We talked about stomas, survival figures, chemoradiotherapy, the emotional side of it, coping strategies. I wrote a referral letter for him to take. I hugged him. He fought back the tears. He went home. Reluctantly—he wanted to see the shift through. It was probably the work ethic that earned him the examination in the first place.

Four hours later, just before the porters came to wheel me to theatre, I made some calls on my mobile. (No one died from the magnetic interference.) I arranged for a trusted colleague—an excellent surgeon and good friend—to see him within 24 hours.

I don't know who to send my bill to. My trust is unlikely to pay the premium "out of hours" rate, because I was supposed to be off duty. It seems a bit harsh to charge his employers, as they have been looking after me very well, even if I could potentially qualify as a visiting specialist. Perhaps his primary care trust would consider a one-off payment. I don't have a block contract with the trust, but the consultation was "patient choice" driven. Or I could set it against tax as a bad debt.

On second thoughts, I won't bill. I never went into this job to make money or because I thought it was 9 to 5. Frightened people need caring professionals, at any time of day or night. That's the buzz—and don't I know it.

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William Harvey Hospital, Ashford, Kent Nick.Taffinder{at}ekht.nhs.uk

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