Category Archives: medical practice

Season 6, episode 7 and the continuing themes

At the 18:07 mark and then again at the 34:19 mark of episode 7 we see a sign on a wall in the background of the scene that reads SECRETS. That, to me, is telling and is the theme of the episode. This episode is very well conceived and executed and begins with Martin hiding his fears about his own condition from Louisa, not being willing to discuss his feelings about his parents and not revealing to Louisa why he can’t go on holiday, Ruth being unsuccessful at prying from Margaret why she’s really in Portwenn, Mike having hidden that he was AWOL from the army and then trying to run without an explanation, and the MPs at first not telling anyone why they’re searching for Mike. Both Al and Joe try to keep Mike from being taken by the MPs by deceiving them.

Secrets, deception, and hidden motives are all methods of controlling one’s surroundings, and that has been one overarching theme for much of series 6 as well as an integral feature of the show (as I mentioned previously in my post about change). This episode magnifies how hard it is for people to change and how that stagnation seriously impacts everyone’s lives. The pivotal scene related to the idea of change/control occurs when Mike has gone to his apartment to pack and leave and still has James with him. It is then that we learn that he is AWOL from the Royal Army because they wanted to “fix” him and his OCD and make him “normal.” But Mike considers the OCD to be part of who he is and doesn’t want to be fixed. Martin shows up at Mike’s apartment looking for James and wondering what’s going on. When Mike explains why he left the army, Martin asks him,”If it wasn’t a part of an order, would you like to feel more in control of your actions?” and Mike answers “Yes.” Martin tells him “the army has a duty of care to you and it’s your decision if you take it or not.” That convinces Mike to turn himself in. This conversation makes it clear that once Mike determines for himself that he is the one deciding to face his demons, he is taking control of his behavior and his life and fighting the control his OCD has over him. Of course, what Martin is telling Mike is what he should be applying to his own situation. It is clear that Martin would like to be more in control of his actions and that he should seek therapy.

When Al takes Mike to the nearest Army post to turn himself in, it is dark and the scene looks ominous with a German Shepard as well as 3 soldiers guarding the gate. Al does what he can to be encouraging, but the setting establishes that what Mike has ahead of him is daunting. Nevertheless, Mike takes the steps toward the gate with some resolve and will, we believe, address his problem with OCD (and with his departure from the Army). This dark and foreboding setting is of a piece with the many other dark scenes in this 6th series. I’ve been troubled by the frequency of Martin sitting in the dark staring into the night and thinking. We can only assume that he’s trying to figure out how he can reestablish control over his phobia and his life. His insomnia is also a side effect of being depressed and he needs help with his depression too. OCD often arises out of an effort by the person to institute control over his/her environment, but ultimately takes control and leaves the person with the sense that he/she is out of control. Phobias are similar in many ways. If one thinks that avoiding a particular thing, e.g. spiders, blood, the outdoors, will prevent them from feeling anxious, and that avoidance leads to a reduction in the anxiety, then the avoidance behavior becomes reinforced. Breaking that cycle is what therapy is meant to do.

During this episode, Martin is shown pondering what’s been happening on several occasions. After Louisa’s accident there are two occasions when he involuntarily falls asleep and awakens to find himself disoriented and disheartened. It’s not surprising that he falls asleep at odd times since he’s been pretty sleep deprived for a while. Lack of sleep along with the depression may also be the reason his behavior at Sports Day is so different from other events Louisa has asked him to attend. Usually when Louisa enjoins him to do something, Martin agrees and tries to handle it as well as he can (e.g. headmistress panel, dinner out, taking James to music time, etc.), but this time he’s not as conciliatory and she finds it embarrassing and infuriating. The whole idea is rather ridiculous since he’s never been good in front of a microphone (think very first episode when Caroline wants him to speak to the town, or Aunt Joan’s funeral) and Sports Day in elementary school was probably painful for him as a child. Louisa should never have asked him to be the special guest and he should never have agreed to do it. Unfortunately, this mistake ends very unhappily and inspires both of them to give some thought to their relationship. We can’t be sure what he is thinking while sitting in the car with James outside the hospital, but he appears to have a sentimental moment when he takes James out of his car seat and holds him up. I could imagine he’s thinking how foolish it was for him to have handled the awards the way he did and prompt Louisa to be so angry with him. Of course that’s speculation. Whatever he’s thinking, it’s serious business and it doesn’t appear that he has any idea that Louisa will decide to leave. As usual, they handle this difficult circumstance the way we’ve become accustomed to: he applies his medical knowledge to her condition while she departs.

It seems to me that he needs regular “wake up calls” to jolt him out of his typical mode of behavior, and she needs to understand that his silence and inability to talk about his problems and thoughts is not in any way related to how he feels about her. Since we know that Ruth will reaffirm his ability to change in the final episode, I expect to see another effort on his part to appeal to Louisa’s better instincts and that Louisa will hopefully recognize that he needs her, loves her, and wants desperately to be a good father to James. He will admit in some way that he struggles to control his behavior, and possibly she will agree to stop leaving. These changes may not be easy to make, but we can hope they will try.

Originally posted 2013-10-17 23:22:38.

What is happiness?

The writers of Doc Martin may not be trying to get into the philosophical definitions of happiness, but the fact that finding happiness is very important in the show certainly makes me want to interrogate it. At the end of season 3 when Martin and Louisa decide not to marry, Louisa tells Martin that he wouldn’t make her happy and Martin responds that she wouldn’t make him happy either.Then in season 6 episode 7 Louisa again tells Martin that she isn’t happy and that she isn’t making him happy. He is flummoxed and can’t understand why people always care so much about being happy. That comment, in turn, bewilders Louisa and she simply gets up to leave. Putting aside the problem I have with Martin saying Louisa wouldn’t make him happy when he’s spent so much time and effort wishing he could have her in his life, and being miserable when it looks like she has rejected him, we can’t help wondering what would make them happy.

If Aristotle is right and “eudaimonia (Greek for happiness) actually requires activity, action,” and that “eudaimonia, living well, consists in activities exercising the rational part of the psyche in accordance with the virtues or excellency of reason. Which is to say, to be fully engaged in the intellectually stimulating and fulfilling work at which one achieves well-earned success,” then Martin’s concept of “happiness” is likely to stem from practicing medicine. However, in recent years the psychologist C. D. Ryff has highlighted the distinction between eudaimonia wellbeing, which she identifies as psychological well-being, and hedonic wellbeing or pleasure. Building on Aristotelian ideals of belonging and benefiting others, flourishing, thriving and exercising excellence, she conceptualized eudaimonia as a six-factor structure:
-self-acceptance
-the establishment of quality ties to other
-a sense of autonomy in thought and action
-the ability to manage complex environments to suit personal needs and values
-the pursuit of meaningful goals and a sense of purpose in life
-continued growth and development as a person
Under this scheme, both Louisa and Martin would struggle to feel a sense of well-being. In particular, Louisa seems to hate not having a sense of autonomy, and she has previously wondered about her sense of purpose. During series 6, we see that she is happy as a mother and is depicted as taking great joy in having a child, and she appears to have a purpose when it comes to being headmistress at the school. What she doesn’t have is the affirmation or reassurance that she is succeeding as a wife and companion. Her autonomy is perhaps compromised most by her inability to get Martin to do almost anything she suggests. He won’t go see a psychiatrist, he won’t talk to her about his concerns, he doesn’t like to participate in most activities, and he doesn’t want to take a holiday with her. Martin seems lost when it comes to feeling in charge of his situation and has not really reached a place of self-acceptance. Obviously his upbringing has a lot to do with this. He feels most comfortable at home and in his routine. On the Ryff scale, he has autonomy but not much else. He does seem to have achieved some sense of well-being from having a wife and child, although at times we’re not sure about that.

I think Martin is right to question why happiness is such a significant feature of life to most people. We can’t be happy all the time. What we need is an overall sense that our home life is satisfactory, that our social lives are fulfilling, and that we have a sense of success in some aspect of our lives. The home life is the one in doubt in this series and Louisa cannot find that place where she is in a comfort zone, while Martin hasn’t really pondered whether his home life is how he’d like it to be. Surely having his mother in the house has changed their home life tremendously. It was somewhat rocky before, but now they have very little time alone and his mother is demanding and quite judgmental. I don’t care who you are, when your mother criticizes you, it hurts.

Marriages all have ups and downs, although this marriage has not been allowed to have many ups so far. Talk about no honeymoon!! Poor communication is often the reason for marital discord and boy is this marriage dealing with that! Ruth can talk to both of them and they are lucky to have someone like her to turn to. They need an intermediary and an opportunity to work together in some way. Go take a walk with James, take a drive somewhere for a couple of hours, go have that picnic Louisa dreamed of (without the earthquake), build something together, whatever. Even if something crazy happens it would still be something they did together and would not take Martin outside his comfort zone. I think they could both be “happy” after that. Louisa’s injury has a chance of bringing them together. We’ll see what happens.

Originally posted 2013-10-15 17:31:57.

Doctors, patients, and stalkers

After learning that Mrs. Tishell returns to Portwenn and will probably continue her fixation on Martin, I realized I should say something about doctors and the real experiences they have with patients/nurses/and the general populace becoming infatuated with them. We also can’t overlook the very real affairs doctors sometimes have with their patients. In addition, in a small town patients and doctors often interact on a social basis even if there’s no intimacy involved, but it can be awkward.

I know about this sort of thing because in the small town in North Carolina where my husband practiced medicine for many years we had numerous encounters of this kind. Sometimes I wondered if we were living in a mini Peyton Place! I guess you could say that doctors are in a position of authority and may often save patients from dire circumstances. Many times patients confuse concern for their health and welfare with other deeper feelings for them. Then there are the patients, like Mrs. Tishell, who have psychological problems and develop delusions that their doctor loves them. In Doc Martin it’s funny that this grumpy and rude doctor becomes the object of the chemist’s affection because most of the town thinks he’s obnoxious and calls him “tosser” and any number of other names. She, on the other hand, tries to impress him with her medical knowledge and does as much as she can to get his attention. He never gives her any reason to think he’s interested in her, but that doesn’t stop her from believing they have a close connection. She’s not really a stalker, but when she cracks and abducts the baby, she reveals how delusional she’s become. In Portwenn, like in the small town we lived in, women could be calling the doc at all hours of the day and night, or leaving him messages on his cell phone, or sending him presents (much like 15 yo Melanie does in season 1, episode 5). Then it’s up to the doctor to figure out how to get them to stop and it’s not always so easy. We shouldn’t forget Mrs. Wilson who also wants to get Martin’s attention and flirts with him. She even gets him to make a house call for a totally trumped up reason. In her case, his status appears to attract her, although she may just be intrigued with making a new conquest. Martin is not susceptible to her advances and his naivete keeps him from realizing what she’s up to. His naivete is probably the reason he never notices Mrs. Tishell’s efforts as well.

I found it very amusing and startling when Martin accuses Louisa of possibly having de Clerambault’s syndrome or Erotomania after their intimate conversation in season 2, episode 8 when he declares his love for her while under the influence of wine the previous night. Here he is staring at her through windows and following her liaison with Danny, and then being obviously relieved when she tells him that she and Danny have split, but he can’t handle it when she comes by the next evening to tell him she loves him too! (Once again the writers, or consultants are pretty amazing with their knowledge of medical terminology.) In their case we have a mutual attraction to each other that must jump many hurdles before and after they finally end up together. Louisa, nevertheless, has to decide how to manage going to Martin as a patient after they establish a personal relationship. Several times she considers changing to a doctor in Wadebridge because of how awkward it is to talk to Martin about her personal health problems. She signs up for prenatal care in Truro, although there are occasions when she ends up having Martin treat her during her pregnancy. Naturally it is odd and difficult to have Martin as her physician when she is unsure of their relationship and trying not to force him into a situation that she’s not sure he wants. Moreover, if they were married, he wouldn’t be her physician. Doctors (by law in America) don’t treat their own families, unless there’s an emergency and no other physician is available.

I can state unequivocally that socializing with one’s gynecologist or gastroenterologist is quite uncomfortable. He’s either done a gynecological exam or a colonoscopy on you and now you’re having a drink and making small talk. The doctors are professionals and do their best to just be friendly, but it’s kind of hard to forget that they’ve been up close and personal with you. I was often friendly with their wives too. How weird is that?

Alternatively, in our small town, there were several physicians who had affairs with patients. Of course, that is considered unethical and, in at least one case, the physician lost his license to practice medicine. But where do you draw the line? What if you are a doctor and you fall in love with someone who lives in your town and who happens to be a patient? In the case of Martin and Louisa, there is some grey area. Both of them are unmarried, they are consenting adults, and there is only one doctor in Portwenn.

But in most cases, Mrs. Tishell is a much better example of what happens. The delusional patient is set right by the doctor and hopefully receives treatment and overcomes her infatuation. Being a doctor certainly involves more than patient care!

Originally posted 2013-10-04 02:58:38.

Women’s issues, part 3

There are many strong women among the characters in this show, besides Aunt Joan and Louisa. I would include Mrs. Tishell, Edith, Ruth, Molly O’Brian (the midwife), Maggie, Elaine, Pauline, and even Morwenna. Many of the aforementioned are professional women who have regular jobs and behave self-assured. Mrs. Tishell runs the pharmacy very competently until she has an emotional breakdown in the last episode of season 5. She stays abreast of recent medical developments and would like to discuss some of these with the doctor. She is very efficient and can offer good advice when needed. She may consider herself a little too much like a doctor (a common concern between doctors and pharmacists), but she obviously wants to be well-informed. I think Doc Martin should be quite pleased that this little village has such a well stocked chemist who takes such a personal interest in providing him and the town with the proper supplies and medicines. She operates the pharmacy alone most of the time, although her husband shows up about midway through the first 5 series. Even after Clive appears, however, it’s his wife who takes care of business and who determines the direction of their relationship.

Edith Montgomery, the doctor and former fiancee of Doc Martin, is depicted as an unemotional and highly accomplished medical practitioner. We can even say that season 4 provides us with an example of a woman working in a man’s world, i.e. Edith as an M.D. surrounded by men and being as much of a hard-ass as any man could be. Perhaps this is a way of addressing the tales of female doctors being tougher than their male counterparts because they are trying to prove themselves. Her fire red, spiky hair and slender, relatively unfeminine figure always dressed in dark colors make her look somewhat daunting. (The writers could have been thinking of Cruella DeVille when they came up with her.) Certainly her approach to medicine and to Martin also reflect a very clinical and passionless manner. (Her personality stands in direct opposition to Louisa who is quite passionate about many things and who takes an interest in most of the people of Portwenn.) Edith attempts to take control of Martin in terms of his future and his effort to overcome his hemaphobia, and in the process she oversteps her boundaries with him. He no longer wants a woman like her, and she unwittingly puts an end to any possibility of reestablishing a relationship with him when she decides to make a hotel reservation for one room without consulting Martin and then removes her blouse to reveal a corset that to me looks like she should be in some sort of S/M setting. She looks like a dominatrix, which is really pretty appropriate. The fact that she has decided to reconnect with Martin when she knows he’s about to have a baby with another woman is rather hateful to me. I see it as another way for her to compete for something just to get the satisfaction of having “won.” She is a stereotype of a female doctor insofar as she fits the profile of driven, striving, dispassionate, and too concerned about showing up the men. I know there are women who are doctors and are like her, but there are plenty who are not. Nevertheless, she has to be called strong and independent, and she has to be added to the number of women in this show who are managing well on their own.

Ruth Ellingham, who is also a doctor, is another contrasting character to Edith while being comfortable by herself. She, too, has never married or had children and she seems very content to live by herself. She talks of being brought up in a family that didn’t allow emotions, but she’s very capable of assessing a situation and handling it well. She has an even temper and a cleverness that make her appealing. Whether she’s dealing with a couple of strange neighbors, Martin and Louisa, Al Large, or PC Penhale, she finds the right balance of straight talk and wit to have a good outcome. Her strength is in her calm demeanor and self-possession. She is a wonderful female character played excellently by EIleen Atkins.

Then we have Molly O’Brian, the midwife, who comes on strong and combative. She may be small in stature, but she packs a wallop. Midwives have become much more involved in births these days, even if the births take place at hospitals. Most work in tandem with OBs and seem to have a good working relationship with them. With Molly we are given a midwife who has some extreme views about where to have a baby and prenatal care. She fills Louisa with all sorts of antagonistic ideas towards men and doctors, and since Louisa is in a contrary mood, she internalizes what Molly says. In the process, however, the show takes on the concerns of mothers about avoiding medicines while pregnant and that hospitals are too antiseptic for having a baby. We all imagine giving birth in a quiet space with our own belongings and family around us, but many births do not work out like that. The fact is that having a baby is pretty risky and not every woman is lucky enough to have the process go so smoothly. Better to be safe in a hospital with the best equipment than risk the lives of the mother or baby. Louisa is a high risk mother due to her age, which makes Molly’s recommendations to have the baby at home in a tub especially foolish. Of course, it turns out that the baby is delivered outside of a hospital after all. At least there are EMTs in attendance as well as Martin, a highly capable doctor. Molly gets her comeuppance when Louisa’s urinary tract infection gets worse after Molly stops Louisa from taking the antibiotics she’s been prescribed. Louisa is, after all, pretty savvy and realizes in time that what Molly has been filling her head with is so much nonsense when it comes to her health and the baby’s. I doubt that most midwives have such anger towards male physicians and believe that Molly is an exaggeration for the purposes of the show. Nonetheless, she never backs down and is a female character who makes an impact.

Finally, we should look at the 3 receptionists: Elaine, Pauline, and Morwenna. Of the women in this show, they are the most alternative in their appearance and, at first glance, would not inspire much confidence in a doctor or his patients. As it turns out, though, Pauline and Morwenna are quite competent and Elaine manages to initiate the doctor into the village. Again, all three are confident and happy to have a job. Although I am a little surprised that Martin takes them on and allows them to come to work in their unusual outfits, they get the job done and sometimes impress him with their efficiency. Elaine doesn’t last very long but may be the reason Martin doesn’t ruffle feathers again by firing any of them. Elaine may not be the person he’d like to see as the receptionist, but getting rid of her proves to be a big mistake because the village turns on him. There are times when one has to respect the will of the people! Pauline and Morwenna are different cases. Pauline has her problems, but she always comes running with his medical bag when called by the Doc, and she wants to take on more responsibilities. She really becomes Martin’s right hand woman who knows him as well as anybody. She can make fun of him, argue with him and criticize him, but he depends on her and shrugs off her comments. (I also love it when she turns the tables on Ross, the town gigolo.) When Morwenna takes over, she surprises the Doc when she saves her granddad from dying by doing CPR. She’s pretty cool under pressure even when she assists on an operation. I think these young women are a good example of not judging a book by its cover. They all find a way to mock the Doc’s problem with blood, they all put up with his gruffness with a sense of acceptance and humor, and they all respect his ability. They may look flighty, but they are far from it and the writers have done young people a service by creating these characters.

This show may be called Doc Martin, but without the plethora of strong female characters, the show would be much less appealing. We need that interplay and it’s great that the writers realized that.

Originally posted 2013-09-13 20:43:15.

Can We Talk?

Why do I feel so disappointed about S8? What is it about this series that simply does not live up to the previous ones? S6 had gotten too dark for me; S7 was too farcical and cartoonish. Nevertheless, I had found plenty to write about and much that made me laugh. This time I have tried to find something that motivates me to write and been struggling. In fact, even the titles of the episodes have not lived up to those of the past. For the most part I have found them trite and lacking any insight into the episode, unlike those of the past.

After doing some thinking, I have come up with the following reasons for my dissatisfaction:

1. To a great extent it has to do with the lack of a story arc for the series. My best guess at one is Louisa deciding to change jobs. It’s the only thread that has continued throughout the series. The only other threads, if we can call them that, are Martin’s blood phobia and, perhaps, the newfound ability of Martin and Louisa to actually get through a conversation without being interrupted. These haven’t been developed enough to carry the series. For some reason the occasions that presented opportunities for worthwhile development were not taken advantage of, e.g. Louisa attending classes with a former student of hers.

2. I am also very disappointed in the writing for this series and in the disjointed plots for each episode. We have previously had episodes in which the main storyline was supported by subplots and in which there were some excellent monologues and dialogues. There were often references to other literary sources or lyrics to songs. There was wordplay and ambiguity. It made the show a fun intellectual endeavor as much as an engaging bit of entertainment.

3. They chose to include almost no affection between Martin and Louisa. In my mind the producers and writers of this show must have been aware that the fans of this show were delighted that the conclusion of S7 reconciled Martin and Louisa and they expressed their mutual love for each other and had a passionate kiss. However, in this series, apart from Martin moving back into the house with Louisa and James, their sharing of duties related to James, and some perfunctory pecks on Martin’s cheek by Louisa, there is precious little to convince us that they are enjoying life together. There are some signs that Martin has taken a few pieces of advice from Dr. Timoney: he makes arrangements for a dinner date with Louisa; he allows Louisa to be “the decider” about James going to a daycare; having a dog; and about the car; and they have a standing lunch date on Thursdays (though we haven’t seen that actually happen). None of these instances leads to any meaningful or affectionate moments.

In this series the most likely bedroom situation appears to be Martin waking up to find Louisa already out of bed. In addition, Louisa tends to be late coming home. James is already in bed, the dog is a nonentity as well, and their conversation rather perfunctory. What happened to those scenes in the bedroom when they talk about a variety of things and actually seem to care about each other like in S5? Why wouldn’t they practice some of the other advice they got from Dr. T, such as saying something complimentary to each other or hugging now and then? Both of them demonstrate concern for the other at times throughout the series, but the deep expression of tenderness and devotion is gone.

4. I am a bit surprised that Martin doesn’t welcome Louisa’s decision to terminate her headmistress position. If anything he should be very happy that she won’t have the stress of the job as well as the course work, and he has always wanted her to spend more time at home with James. Although I would imagine James would still go to daycare regularly, Louisa might be available to drop him off and pick him up as well as find days when she could keep him home. Quitting her paying job is a big move for Louisa since she has never wanted to be a “kept” woman. By considering this change, isn’t she indicating that she’s willing to relent in that area, and perhaps even showing a willingness to trust Martin as her partner? (The fact that he may be forced to take a break from his medical practice and their source of income may be up in the air has not entered into her decision at this point.)

[I want to take a time out here to mention that I have looked up what is the likely procedure for filing claims against private physicians in the UK. According to a site I found that provides the rules for Medical Malpractice Liability in England and Wales, most GPs are covered by the Medical Protection Society and it is they who “will provide advice and may undertake the defense and settlement of the case.” It would be unlikely that he would be forced to stop practicing medicine; his practice manager (Chris Parsons) has recommended that he stop seeing patients until this claim is settled. However, from my perspective this patient will have a hard time proving that ME is incapable of taking care of patients, especially after this series has been chock full of patients he has treated and whose lives he has saved. Moreover, she did not follow his medical advice and there are plenty of witnesses to that.]

5. Despite the assertion that they don’t want to repeat themselves, they have been doing just that. Here is a quick list of the many repetitious scenes they have used this series:

  • A contagious disease that affects a group and ruins a party
  • A professional woman self-medicating and becoming crazed. This one, in particular, bothers me. Is this such a pervasive problem in UK that we have it appear so often in this show?
  • A wedding that is called off and the bride leaves town
  • Bert serves tainted food or water
  • Bert lies about where he’s sleeping and how his business is doing
  • Ruth has to warn Al and Bert about her lack of confidence in them
  • A woman uses shells and other “detritus” to create jewelry
  • Mrs. T acts the fool around Martin even after recommitting to her marriage
  • An older woman malingers in Martin’s surgery

6. There are glaring gaps. For example, who buys the farm? Why does James never say another word? Who the heck is Ken Hollister or Hannah Butler or Trevor Dodds? We’ve seen a lot of characters come and go, but these seem to be regular members of the town that we’ve never met before yet everyone knows them. And why isn’t Hannah more upset about the loss of her tent, much less the safety of her guests?

We would wonder about the farm because it has been in the Ellingham family for many years, it’s been a fixture in this show, and we would suppose that whoever buys it would be important to them and the show; we would expect James to say more than one word by now; and we have been introduced to many of the townspeople throughout the show, but Ken owning the pub comes as quite a surprise.

How did Martin’s foot tendon heal so quickly? And Angela Sim’s compound fracture of her clavicle? She doesn’t seem to be in much discomfort when we next see her. How did Mrs. T suddenly become more capable of functioning without therapy? Whatever happened with James and the biting at school?

7. With so many new characters appearing constantly, the show has become choppy with little connection between one episode and the next. Only Angela Sim has returned for a second episode, and then very briefly. I could have imagined her nephew Toby appearing again.

8. In their effort to have some sort of excitement in each episode they have gone to extremes to find medical conditions to take up the time. There are so many incidents in each episode that nothing is fully explored and it’s easy to lose track of what each episode was about. As mentioned before on this blog, plot requires conflict. Where’s the conflict in this series? It’s fine to show Martin and Louisa having a calm home life, but let’s have some spats that typical couples have, and they used to as well. Everything has gotten too sedate. It’s only in S7 that we see the beginning of some action that might not be resolved so quickly.

9. The dog on the bed is particularly inexplicable to me. Louisa has now gone from wanting Martin to get the dog out of the bedroom to allowing the dog on the bed; Martin has gone from throwing the dog out of the bedroom window to ignoring it. Once that takes place, the whole dog issue falls by the wayside very quickly. The only practice he continues to do with the dog is wear gloves to handle it. Is that a gag that is supposed to be funny every time? Even when the dog chews James’s teething ring, nothing about the dog develops.

10. Finally, the routine behavior of the key members of the cast has now grown stale. Some of you find Morwenna and Al more grown up and Penhale somewhat more capable. I don’t see that so much, and I definitely don’t see a change in Mrs. Tishell or Bert at all. Their comedic gimmicks are the same old stuff and they are no longer funny (or even pathos inducing).

I have held Jack Lothian in high esteem for many years and had hoped his larger role as show runner this series was going to add all sorts of enlightened storylines and humor. It is a particular letdown to me that that hasn’t happened. This blog has been my way of admiring the show through analyzing it. Writing the above is painful for me.

Doctors and their medical practices

Once again I’m writing something else before writing about women’s issues. I felt pressed to write this first because I see that the first episode of season 6 will be aired in the UK on Monday night at 9 pm. I noticed in the trailer that was released that Doc Martin’s bedside manner (or lack thereof) is once again a major concern and I really want to discuss that.

Doctors in the US have a saying that patients are most concerned about the 3 As: first affability, next availability, and finally ability. Of course, this is simplistic, but it says a lot about what patients often use as a guide when dealing with doctors. Throughout this show Doc Martin’s gruffness, rudeness, and all around anti-social behavior have been a topic of conversation. At the same time, his complete dedication to doing the best job possible and his amazing ability to determine what is causing a patient’s symptoms have been topnotch. Over the 5 seasons he has diagnosed all sorts of unusual medical problems and often without anything more than his own keen observation and examination. I have been more than impressed that the show includes examples of Sjogren’s, Cushing’s, Addison’s, Reiter’s, Methanol poisoning, and Trimethylaminuria. There have been cases of HRT therapy leading to the growth of male breast tissue, glaucoma, allergic reactions galore, poor diabetes control leading to the person slurring her words and being accused of excessive alcohol use, and even the mixing of medications that can be dangerous if combined. Could one doctor be this capable of recognizing all these disorders? I think so, and I think the show does a good job of making Doc Martin’s ability incredibly believable. (I don’t want to neglect to mention that this doctor shows remarkable willingness to call an ambulance and that he is fortunate that this small village has such access to emergency services. It’s great to see a doctor who has no hesitation to call for help and that is another sign of a very capable physician.)

I do not think that all doctors are as knowledgeable as Doc Martin, but I think that there are some who are. I also believe that there are doctors who care as much as he does about medicine and devote themselves to their practice like Martin does. Many doctors are on call (or available day and night) at least some part of every week. I don’t see them running down the street to get to a patient in need very often, but they will meet a patient in the ER or their office when necessary. There are few doctors in America who will make house calls like Doc Martin does regularly, but they’ll talk to you on the telephone and make time for you at all hours of the day. And that brings up another part of being a doctor that accompanies this availability: interruption of their personal lives. Yes, in the show it’s amusing that Martin’s phone often rings at the most inconvenient moments, but that really happens in doctor’s lives all the time. Do people actually come up to doctors at the most inappropriate times to ask medical questions? YES! My husband has been disturbed at concerts, in restaurants, at the fitness center, almost any place he goes. Maybe the weirdest was while he was with one of our children while they were in the middle of a swimming meet. In a small town the problem is worse because it’s impossible to go anywhere without bumping into patients. One reason Martin may not want to go out is because of the hassle of encountering patients. Just look at what happens when Martin meets Louisa for dinner (or doesn’t get through dinner because of a patient), or wants to have a drink with her only to be taken aside by someone else. His directive to make an appointment may sound brusque, but it’s the best way to set some boundaries.

As far as bedside manner goes, establishing rapport can be important, but it’s probably more important in a large city where it’s harder for patients to get to know their doctors. In a small town where the patients are familiar with their doctors there’s a little more leeway. Nevertheless, Louisa makes a point of telling Martin that the people of Portwenn like having a doctor who becomes a part of the community and there is clearly a concern that doctors in England pay special attention to getting along with their patient population. Witness the “doctor’s friend” Gavin Peters who appears in season 2, episode 9 and says he’s a liaison between practitioners and the local medical committee. From what I can gather, all doctors in England are supposed to register with the General Medical Council and then be subject to reviews of their services. I’m sure most doctors don’t like this supervision and Martin is no exception. Gavin tells Martin that patient care is not only about proper diagnosis but that doctors also have a pastoral duty. I don’t know about the necessity of a doctor to minister to a patient, but the most important part of creating a good connection with one’s patients is being able to elicit information from them that can help in their care. Doc Martin seems to know the right questions to ask and generally manages to get a good read on what’s going on with his patients. His observational skills are his best tool. The one time he would have been been better off being more sympathetic was when Phil’s wife Helen dies suddenly in season 2, episode 5, and Aunt Joan let’s him know it. A patient’s death or serious setback requires some kindness from the doctor, I think. But don’t forget that Doc Martin several times keeps people from dying and a few of those cases are people he isn’t too thrilled about, e.g. Danny, Eleanor, and even Holly. Saving their lives demonstrates how doctors treat anyone in need no matter their personal feelings. You might think that Martin is simply treating the medical problem and not the person, but you have to expect him to have some thoughts about who he’s rescuing.

The other thing that’s significant is how much he believes in patient confidentiality. That point is driven home time and again when he refuses to discuss a patient with anyone else. In such a small town maintaining confidentiality is particularly paramount since pretty much everything that people hear gets spread around quickly, e.g. his hemaphobia, or that Phil Pratt is gay. Besides, doctors are expected to keep their patient’s problems private and most follow that dictum wholeheartedly.

What Doc Martin lacks in people skills he more than makes up for in diagnostic skills. And he does care enough to literally tramp through the woods in search of a sick patient, or climb a ladder and risk his own safety to reach a patient, or, worst of all, rappel down the side of a cliff to help a patient. Ok, there is some humor in seeing him go to these lengths, but at the same time, he is totally committed to taking care of these people. When Martin has outbursts where he yells at patients, it’s primarily a sign of frustration that he’s trying to help them and they won’t allow him to complete his exam or treatment of their problem. Once again most doctors experience this frustration; they just don’t run after the patients yelling epithets. However, they’re probably thinking exactly what Martin actually says. Furthermore, using the internet to diagnose one’s symptoms is something I believe doctors universally deplore. I think we all want to look up what might be going on with us, but there is a lot of information on the internet that is unreliable or simply wrong. When patients come to a doctor convinced that their symptoms are one disorder or another, doctors have to conquer preconceived notions as well as do their own exam. It often adds an unhelpful layer of complexity and Doc Martin’s disgust with this practice is very much in line with the approach of most doctors.

Ultimately, the people of Portwenn know they have a doctor who is dedicated to their care and I’m pretty sure his ability is more important to them than his affability.(Dr. Dibbs provides a counterpoint to this issue of affability versus ability. When she arrives in town, some patients she treats find her very pleasant and are quick to consider her a welcome change; however, it’s not long before her lack of ability becomes apparent, and by the end of her brief stay in Portwenn, the people are very glad to have Doc Martin back. Dr. Sim may have been just like that too – the people liked his affability, but his ability was sorely lacking.)

Originally posted 2013-08-31 02:58:12.

What’s in a Name?

In this post I want to consider what Doc Martin’s writers have done with names in the show. Doc Martin himself is, of course, not happy with being called Doc or Doc Martin; he’d rather people use Dr. Ellingham. But throughout the show, most of the town call him Doc or Doc Martin with the exception of Mrs. Tishell who honors his request and uses his last name. And she, in turn, is generally referred to by everyone as Mrs. Tishell. Indeed no one uses her first name until her husband Clive returns. Edith only refers to Martin as Ellingham, and that seems to be her way of being both familiar and equivalent. To me, it is also the mark of someone who distances herself from the others in his life. (In a nice twist, Edith doesn’t remember Joan’s name and calls her Jill.) Louisa, on the other hand, prefers to use Martin when talking to him and we can’t help but see her as closer to him as a result. Louisa has been involved with deciding whether he becomes the new GP which gives her greater standing to use his first name, and she refers to him as Dr. Ellingham when in a formal setting. So we have the title of Doc, the first name of Martin, and the last name of Ellingham all being used in relation to the doctor. (I can say that in my experience, my husband wanted patients and staff to call him Dr. plus full last name because he had earned it and he felt it was the correct way to address him. His office manager/receptionist did use his first name when speaking to him directly, however.) Martin’s receptionists all default to Doc.

Despite the doctor’s own hangups about his name, he usually cannot remember any patient’s names. This is both humorous and realistic since it is not unusual for doctors to have trouble remembering patients’ names and they typically remember people by their conditions/diagnoses. (My husband can still tell you about a patient’s symptoms from years ago but could not dredge up the patient’s name if his life depended on it.) In the show, there are plenty of times when it’s funny to see the Doc use a variety of names for one person. Episode 6 of season 5 stands out to me because Doc M cannot get a handle on the school maintenance man’s name. Louisa reminds him several times that the man’s name is Mr. Coley, but Martin uses Mr. Creely, then can’t come up with a name, then calls him Mr. Munson. Of course there are many students whose names escape the Doc. Louisa, like most teachers, objects to not using the child’s name and reminds him that it’s Adam who has been throwing up or Elliott who has slapped-cheek syndrome. Martin refers to Elliott as “your boy” and his parents are insulted by the doctor’s off-hand treatment of their son and unclear answers. There are any number of other students/children who Martin refers to as “that boy” or something of that nature. To Martin, these names are unimportant; what’s important is getting the right diagnosis and treatment. On the other hand, the names of diseases, syndromes, or other medical problems are never hard for him to remember no matter how complex or esoteric. Those he remembers without even a slight hitch.

Of course, the naming of his own child turns into a major bone of contention. We don’t really get into which last name they plan to use except when Louisa notes as an aside that he will be using her last name. The fact that she and Martin aren’t married means that a last name will be another decision they’ll have to make. I find this concern quite contemporary, although the English may have more of a history with determining last names due to their royal family. In the last 30-40 years we’ve had women (and some men) retaining their last names, using their original last names professionally but not in their private lives, hyphenating their last names, or going the traditional route and using their husband’s last name.

But it’s the baby’s first name that gives Martin and Louisa troubles. It’s awkward (and funny) when Bert does the rather English thing of taking odds on what they’ll name the baby while Louisa is in labor, and Martin comes in 500 to 1. The name Martin never does enter their minds. The first thought Louisa has is to name the baby Terry after her father, a name Martin finds too common (both in terms of its social status and in terms of its frequency). Then we have the amusing scene in which Louisa deliberately calls the baby Albert, which makes Martin stop in his tracks. She frustratingly tells him they have to call the baby something: Steven, Paul, Michael, Elton, whatever. Does that mean Louisa just wants to settle on a name and isn’t too concerned what the name is? Hardly. When they find a time to seriously discuss the baby’s name, she battles with Martin over whether to use her grandfather’s name first or Martin’s grandfather’s name first. At least they’ve decided to use both grandfathers’ names. Ultimately, their conflict is resolved by Martin who reaches the conclusion that he should give in and let Louisa get her choice, but not without some discord. He’s made out the papers without telling Louisa and she justifiably (I think) resents that. So the baby finally has a name (James Henry) and Louisa feels satisfied that it’s the name she preferred.

A few other thoughts come to mind about names as they are used in the show. We have the family name of Wenn that appears to refer to the name of the town, and there is a woman whose surname is Braithwaite (a likely reference to Philippa Braithwaite, the producer and wife of Martin Clunes). Then there is the doctor’s third receptionist, Morwenna, who tells the Doc that she was named after a Cornish saint and who tells him the most popular boy names at the moment. In addition, Morwenna laughs disbelievingly when a patient tells her that her baby’s name is Boris. She realizes pretty quickly that she shouldn’t have laughed, but the point is that some names seem right and some seem wrong depending on the place and time. In fact, even Louisa asks Martin to refer to her as Miss Glasson when he’s at the school.

We can’t overlook the use of childhood names, names of endearment, or aliases. Louisa was called LouLou probably as a child and some of her friends from childhood still use it, e.g. Danny, Holly, and Isabel. Her mother calls her LouLou too. It’s more or less one of those names we never get past even if we aren’t too thrilled to be called by that name anymore. Those names sort of straddle the endearment category and the juvenile. However, sometimes turning a child’s name into something that sounds endearing doesn’t sit well and when Louisa’s mom calls James Henry “Jim Jim,” Louisa tells her right away that’s not his name. Martin’s Aunt Joan is called Auntie Joan affectionately by him many times and she calls him Marti. When she uses that shortened form of his name, we know it’s meant to be affectionate, but when John Slater, Joan’s former lover, calls Martin “Little Marti,” we recognize the condescending tone it takes on. The older man rubs Martin the wrong way, especially when he reminds Martin of wetting his pants as a boy. There is also the foreshortening of names, e.g. Mags for Maggie, or Sal for Sally, that is supposed to be a sign of affection. Then there is the complication of Mark meeting and falling in love with Julie only to find out that she has been known by several other names, and not for good reasons either. Her change of names is a sign of deceit and reveals her devious nature. The final comment about name use I would make is that stating a person’s name with a certain tone can indicate anger or frustration as when Louisa calls her mother “El-i-Nor” with a snarky edge to it. It’s all in the tone and the relationship of the name callers to their subjects.

What’s in a name? Well, family significance, status, collaboration, trendiness, even historical meaning. There’s also something to finding a name that can distinguish you from the crowd, and that fits you in some indefinable way. The most important essence of a name, however, is that it identifies you and your position. When people remember your name, it makes you feel valued. Using the proper title shows respect and not using it can be viewed as being inappropriately familiar. Your name places you in a culture and in a time period, and that sometimes can either assign prominence to you or stereotype you. (For example, I know someone whose first name is Osama, but he goes by Sam for obvious reasons.) Names are signifiers and, as such, are an important part of who we are.

Originally posted 2013-08-11 20:42:59.

How’s the Therapy for You?

We have now come to the end of S7 on AcornTV, and that means I feel free to publish my thoughts on a number of things about it. Here is the first of several posts:

During the promotion for S7 marriage counseling/guidance was brought up as a key facet of how Martin and Louisa would be dealing with their marital problems. Since “Doc Martin” is a dramedy, we would be surprised if there were a lot of lengthy counseling scenes; however, in the operating room scene at the end of S6 we heard Martin tell Louisa that he needed help from her to become a better husband. Prior to that we heard Ruth tell Martin that if he wanted to get Louisa to return to him, he would have to work hard to change. It didn’t seem like too much of a leap to expect some real effort to use marriage guidance to improve their marriage.

We have been through 6 series that have contained many medical emergencies and lives saved. We’ve learned about a myriad of rare medical disorders and all have been treated properly by Martin Ellingham with an expertise that demonstrates his superior medical knowledge and skill. We would expect no less from any depiction of marriage counseling. Sadly, that is not what we get. The following is my view of the marriage counseling and where it disappoints. Whereas we can learn about how to diagnose and deal with a variety of medical conditions from watching this show, we should not accept what we see in S7 as a good representation of marriage therapy. (Abby and Santa, regular participants of this blog, reviewed what I wrote and provided me with feedback and their professional experience. Abby is a practicing therapist who sees married couples for counseling and Santa is a retired therapist. They have written some previous posts on psychological aspects of the show and its characters.) This post is intended to focus on the accuracy of the therapy sessions first. I will add a few thoughts on the purpose of the therapy scenes at the end. Please bear with me on this because it’s going to be a long post.

In series 7 each episode includes a brief look at therapy sessions. We have to keep in mind that what we are shown is only a couple of minutes of each therapy session that is scheduled for one hour. I would like to think that what they choose to show us is the most important exchange of each session, but no 2-5 minute interlude can give us a sufficient amount of information. We are left with many unknowns about the therapy. Nevertheless, I don’t think it’s fair to excuse the problems with how the therapy is depicted simply because of the brevity of what we’re shown.

Our first introduction to the therapist recommended by Ruth is that she conforms to how Ruth described her, i. e. she is a no nonsense, direct person who has set standards and practices and will not change them for anyone. She demands that Martin shut off his phone and leave it at the entrance to her office; she tells him that being late for any reason is unacceptable and could lead to a termination of their sessions; and she won’t be deterred from treating his problems by any questions he poses about her background and reason for being in Portwenn. She won’t allow him to usurp her role as leader in this setting. These rules seem a little too rigid because he is the only doctor in Portwenn. According to Abby, it would have been better for them to clarify what constitutes the kind of emergency that would be an acceptable reason for him to arrive late for a session. Dr. T wants him to make therapy a priority and the act of discussing this issue would be a good way to convey that message.

Her approach appears to work well with Martin and he exposes more of himself to her than we’ve heard him tell anyone else, including Louisa. He recognizes that due to his being an unwanted child he has an inability to form adult attachments; he exhibits poor communication skills; he has unrealistic expectations of others, and a blood phobia. Of course he’s done his homework and decided what her diagnosis will be, but she is quick to brush off his easy judgement and makes clear that therapy is not like surgery; it’s a process. Although Dr. T appreciates Martin’s effort to arrive at a diagnosis, she doesn’t dispute it. Abby notes that “the first order of business, other than taking a history, is to establish a therapeutic alliance.” We can now look forward to watching the process proceed. We have set before us a series of issues that Martin has delineated and that we would assume will be how Dr. Timoney will plan her therapy.

Dr. Timoney begins quite understandably with asking Martin what he is coming to her for. He tells her, after asking her about herself, that he wants his wife to return to him, that he wants her to be happy, and that he blames himself for her unhappiness. Dr. Timoney’s first command for Martin is she wants to meet Louisa. That seems reasonable since Louisa plays an important role in the direction of the therapy. On the other hand, Martin probably has no idea when Louisa will return and appears to have neglected to tell Dr. T that important fact. Fortuitously, Louisa returns soon after, and that night over dinner Martin has a chance to inform her that he’s been seeing a therapist and that she wants to meet Louisa. Luckily, Louisa agrees to meet Dr. T even though she has some reservations. She figures she’s going to shed some light on Martin’s problems for Dr. T. In other words, we start therapy on tenuous footing including that as far as we know Martin has only seen the therapist once prior to Louisa’s return, due to time constraints he needs her to agree to see Dr. T on the same night that they are reunited, and he tells her nothing about his session with Dr. T.

When Louisa meets Dr. T for the first time, we see her enter the building but it appears that we pick up the conversation sometime after it begins. By the time we are brought into the conversation, Louisa is in the act of explaining that Martin has a hard time expressing his feelings, although she’s sure he loves her. Louisa then makes some derogatory comments about Martin’s parents, all deserved. She is especially clear that Martin’s mother is very cold and that she can understand why Martin is emotionally repressed. When asked about her parents, Louisa identifies them as normal, but she does reveal that her Mom left home when she was 12 and that her father was incarcerated when she was a child.

Since the show has made a fairly consistent effort to inform us of the childhood traumas of both Martin and Louisa, we have been led to believe that these are critical to the formation of these two characters. We’ve met all four parents over the years and, through a dream sequence that Martin has one early morning after James has been born, and probably triggered by a butterfly crib mobile, we know that Martin has suffered from the harmful effects of a bad tempered father when he was young. We also know that he’s been punished by being locked in  a space under the stairs and by physical means, and that he wet his bed until he was 11. Thus, when the counseling sessions begin with Dr. T learning some intimate tidbits about their parents, we anticipate more inquiry into the parent/child dynamic. Childhood is when the most significant impact on our lives occurs and we deem it crucial to this couple. But that is not to be after all.  Dr. T does not pursue this line of analysis and we do not hear her ask much about their childhoods after this. At the very least a good therapist would have explored how these experiences may have negatively impacted how Martin and Louisa relate to each other. The best therapy would have delved into their childhoods and considered how these experiences shaped them.

Instead, even though Dr. T wonders whether there is some connection between how Louisa’s relationship with her father might correspond with how she deals with Martin, she decides that it would be best for them to enter couples therapy. There is no transition during which she looks into Martin’s individual concerns. Since he made the initial contact, she might have wanted to probe more deeply into Martin’s feelings about why things were difficult before Louisa left. What does that mean anyway? Moreover, we see Louisa immediately resist the notion of couples therapy. We also note that Louisa is not receptive to the suggestion that both parties may be in some way responsible for the problems. Nonetheless, Dr. T moves on with couples therapy without a second individual meeting with either of them. Once therapy transitions to couples counseling, the objective changes. In couples counseling it is the marriage that is effectively the client and not any individual. The mission is now to set goals for the marriage to reach a satisfactory level of success for this couple.

Our introduction to couples therapy with Martin and Louisa begins with E4. When we join the conversation, Martin and Louisa are already seated facing Dr. T and Martin appears to be answering a question about whether he thinks environment has a strong impact on personality development in children. For some reason he mentions that his parents would leave him with his aunt every summer as related in some way to his conclusion that environment is important. Once again, Dr. T does not follow up and asks nothing about his relationship with his aunt or about what visiting her might have meant to him. (From what we’ve seen, we would think that it was a very positive experience during which he received the love, affection, and acceptance he had been missing at home.) He has mentioned that he was an unwanted child, which is pretty significant, but has left out the abuse and neglect he suffered. Most therapists would have wanted to know what brought him to the conclusion that he was unwanted. But here Dr. T moves on to asking Louisa if she’s uncomfortable. (Abby writes that she would have asked Louisa what it was like for her to hear what Martin is revealing. She notes that “it is important to develop empathy between them” and that Dr. T’s question about Louisa looking uncomfortable could have been a good way to transition to this. Unfortunately there is no follow up that takes place.)

Both Martin and Louisa look uncomfortable, and the seat they are asked to use certainly seems very hard and stiff itself, but also they are estranged and have never been extremely prone to overt expressions of affection, especially in public. Martin asserts that he appreciates Louisa, which is more evidence of Martin trying to change and become more expressive. This leads to Dr. T asking whether Louisa considers Martin appreciative. She rightly says that to her he is usually quite nice but not so much to others. Dr. T appropriately cuts Louisa off once she gets going on listing all the things she finds troubling about Martin, and we get the impression that Louisa has a lot of pent up criticism about him. It may be a sign of Dr. T’s observational skills that she notices their self-containment and asks them to list three positives about each other. Louisa is able to produce three things fairly quickly, and they are telling in that they are rather impersonal: Martin is a good doctor, he dresses smartly, and he keeps the house tidy. This last item is strange to find on Louisa’s list because she usually isn’t so happy about it. Then it’s Martin’s turn and his list is much more personal: Louisa is a good and caring mother, she’s active, and she’s very beautiful. Their choices represent well what is important to each of them. For Louisa Martin’s outstanding medical ability has always been preeminent. She is also attracted to his outward appearance and professional attire. After that she seems to struggle for a third thing to add. For Martin Louisa’s interest in being a good mother is preeminent and why he has nothing to say about her achievements as headmistress. Being active matters to him on a health level, and we know he has considered her beautiful from the moment he first saw her. Louisa seems flattered despite the omission of her ability as a headmistress.

What follows is an assignment to hug three times a day and say something positive to each other every day. As I wrote in my post on Hugs and Kisses, this assignment makes sense because it asks them to add physical touching, and that can be extremely effective in bringing people closer. It also requires them to think of something they can say to each other that should be complimentary. It switches the emphasis away from the negative.

As always, we know that watching Martin and Louisa hug three times a day will be both amusing and endearing, and it is. This was precisely what I hoped therapy would do for the show and this couple. By the end of E4, we see a lot of progress even though Louisa still struggles to find something positive to say to Martin. Therapy is making a difference despite being relatively lacking in thoroughness.

E5 starts with Martin already having a bad day due to an unpleasant confrontation with a young girl and being shadowed by Buddy. They arrive a bit early for their therapy session and are seen waiting in their car by another patient, something they both appear to dislike. Dr. T asks about how the hugging assignment went and Louisa answers that Martin has trouble with spontaneity. Martin immediately accuses her of the same. But we are quickly off to Louisa asking about doing something with Martin’s blood phobia. Louisa has finally raised that condition with Dr. T.  because she would like to redirect therapy to make it about Martin. At this point, according to Abby, most therapists would acknowledge the importance of Martin’s haemophobia but make sure the hugging exercise wasn’t neglected. There was too much material involved with the hugging for the therapist to simply move on without spending more time on it. Dr. T can’t really address the haemophobia specifically with Martin if she is focusing on the marriage, but she suggests the blood phobia is connected to Martin’s desire to be in control, and despite his disagreement with that, she sticks to her analysis and gives them another assignment. (There is some dispute here about the origins of the haemophobia because we’ve heard Ruth tell Martin that this sort of phobia often has roots in childhood trauma. Abby would be inclined to agree with Ruth even though Martin certainly has control issues. As a person who needs to feel in control, Martin probably felt safe until the event that brought on the blood phobia took place. The onset of the phobia was enough to bring on significant anxiety and make him terrified. Since then, he has found a way to maintain control, but each time the phobia reappears, it reminds him that he isn’t in control and he is thrown into another state of fear.)

This time their assignment is for Louisa to take charge of an activity and Martin must do whatever she asks of him. The odd thing about this is that he’s trying to do even more than that already and has chosen to live in an unsavory place so that Louisa and James can stay at the surgery. He also offers to bathe James regularly and to take care of James when Janice is unavailable. He’s very cognizant of not impinging on Louisa’s privacy and treads lightly around her. But both Louisa and Martin agree to this assignment without objection either.

The picnic Louisa chooses as her activity is disrupted by Angela Sim having a mental breakdown at the beach and that breaks up the family occasion. On the other hand, Louisa is grateful that Martin was there to help Angela and the episode ends with both of them entering the surgery together, which should be a good sign. Then again, there is no mention of how that assignment went to our knowledge but we join the session near the end this time. (Abby finds this assignment strange because Dr. T should have noticed that both Louisa and Martin have control issues. Louisa has tried to take charge of most of the sessions. “If she gave them this assignment to show how Louisa sets Martin up, then why wasn’t the assignment explored the next session?  Why did you choose a picnic?  Is it something you thought Martin would like?  What food did you pack?  Were there things both of you like?  So much valuable material that could have been gleaned from a discussion like this.”)

Once again Dr. T decides to give them another assignment which entails going on a date together. Dr. T makes a valuable contribution when she comments that Louisa may equate love with being left alone, since her parents left her when she was a child, and now she has fallen in love with a man who she says she didn’t think would last in Portwenn. Her comment that Louisa sets Martin up for failure is also so that she can continue to be disappointed in him. Abby notes that Dr. T was planting seeds that she hoped would germinate either during therapy or afterwards. Each time in the world of Dr. T’s therapy, however, there is so little follow up that we can only be frustrated, and that shows poor practice methods.

It is here when Louisa admits that falling in love with Martin was not a conscious act in any way connected to how she might conceive of the emotion of love. Perhaps that is a nod to the incomprehensibility of choosing Martin as the man she wants to marry. We can’t explain what leads us to fall in love and love is rather mystifying. Again, as far as we can tell, Dr. T just leaves that hanging too.

Dr. T provides very few guidelines for the date so it’s particularly nice to see Martin bring flowers for Louisa, make reservations at the location where they first met and make special note of that. They have a slightly tense conversation about Louisa’s impression that Martin wouldn’t last 5 minutes in Portwenn. Then Martin brings up Danny and confronts Louisa about telling Danny about their private lives, but Louisa is honest in her answer and quick to apologize. For me her behavior is conciliatory and she hopes to have a nice dinner. The disruption comes when Louisa takes a call from Danny that causes her to feel compelled to leave. It is understandable that she would leave her phone on to be available for any calls about James, but she should never have accepted a call from Danny, and he should never have called her.

When Dr. T sees them next, Louisa describes the dinner date as a disaster, but that seems a pretty extreme appraisal. Again, Dr. T does not ask Martin to venture his own feelings. Martin’s anger at Louisa for divulging their marital problems to Danny is not similarly played out with Rachel. Time and again Dr. T allows Louisa to be the one to give her evaluation of each exercise with no effort to balance what she says with what Martin thinks. Quickly Dr. T comes to the conclusion that Martin and Louisa should make a list of what they like about being on their own, and tells them they should not consider a decision to separate as a failure. (Abby can’t help having a strong reaction to this procedure, and I decided to include it all: “This scene is so far from good practice that I cringe at the thought that people will think this is what therapy is.  First of all, she doesn’t explore why Louisa found that date to be a disaster.  ((Santa would add, “If there’s anything that’s not typical of therapy, it’s letting pass a pregnant comment that ‘it was a disaster.'”)) She didn’t elicit Martin’s view on the evening.  She didn’t explore the entire assignment:  How was the date arranged?  Who asked whom?  Did Martin pick her up?  How did that go?  What was the drive like?  Where did they go?  How did they feel sitting at the table with each other?  What did they talk about?  Where did the evening break down?  Was there a better way they could have handled it?  There was so much that could be gained from such a post mortem that it is frustrating for me to see it just dropped.  And then to suggest they think about the positives of being separated after such a short time leaves me just dumbfounded.  One might wonder if she was using reverse psychology here, but that would be a very dangerous game.”)

It is also very bad practice to have never explored the history of their relationship and the course of their short marriage. We have no evidence that she ever has tried to investigate these areas.

What we have then is several short-lived efforts to spend time together, hardly any review of what took place during those occasions, usually a willingness to hear only one person’s assessment of the assignment, and ultimately a suggestion that perhaps saving their marriage is not such a good idea, and that that would not be considered a failure.

The final time Martin and Louisa go out to see Dr. T takes place after Dr. T’s car accident and head injury. She acts very erratically and chooses an exercise for right there in her office. It seems a bit silly as she asks Martin and Louisa to march in place. We can no longer take her seriously as a therapist.

When we make a final survey of the therapy, it is hard to be very impressed by it. The length of time they spend going to therapy as a couple is probably 5 weeks. Over that period Dr. Timoney has learned that both Martin and Louisa had childhood experiences that were damaging and are likely to have caused some residual harm. In Louisa’s case she has concluded that Louisa interprets love as being intertwined with being cast aside; we don’t know how she looks at Martin’s childhood. What she thinks about Martin is that he likes to be in control. She notices that they are self-contained, at least around her. Hopefully she also realizes that Louisa has a good deal of bottled up anger toward Martin based on how easy it is for her to express criticism of him. She should also notice that Louisa is usually the first one to give her impression of how each assignment went, and that she often does not reciprocate Martin’s efforts to offer compliments. We see almost no follow-up after Louisa disparages each assignment, and there is very little probing of either Martin or Louisa. Without asking for more information, how can you trust that what’s reported is accurate? (I would argue that it isn’t accurate or reliable.) Needless to say, I would expect a therapist to inquire why Louisa is so angry at Martin and possibly elicit from them what it would take for her to be able to get over her strong vexation with him. It seems clear that Louisa is the barrier to any reconciliation. Furthermore, as Santa notes, “they were never coached in how to talk to each other, which I would think would almost immediately have been identified as a significant issue for them.” Martin has admitted to having poor communication skills. We know that this show is built on Martin and Louisa being unable to complete most conversations for many reasons. It would have made sense to address that.

There are many other problems with the therapy and its short term basis. Most therapy lasts for several months, not several weeks. The marital troubles have built up over a fairly long time and dealing with them cannot be expected to work so quickly. Certainly, any couples therapist would do her best to find a way to keep the couple together, especially since that is why they have engaged her. To give up and advise them to separate after such a limited time trying to help them, would be a sign that this therapist is lacking in proper skills and not gifted as advertised. Both Santa and Abby concur on this point.

(As often happens, I read an article in the NYTimes that seems pertinent and wanted to share it with you. It’s helpful that the article provides both sides of therapy and this therapist is loathe to end therapy when she feels there is still much to work on. Importantly, she notes her own failures in treating this patient and hopes to be given another chance to help. Unlike Dr. T, she does not tell the patient that she is an extremely challenging case and she never implies that the situation is hopeless. What Dr. T says is extremely unprofessional, according to both Abby and Santa. To quote Abby: “You do not tell a couple that they are the most challenging case you have ever come across, especially when the therapy has not been successful.  This is very blaming, and in a more sensitive client could induce shame.  It is important to end with something positive, if only with an invitation to return when and if the client feels the need to do so.” Santa adds: “We understand dramatically why she said it — to build suspense about whether they can reconcile — but it’s just dumb.” Having this doctor behave in an obviously grossly unprofessional manner and say something plainly stupid puts in question how Ruth portrayed her originally. Maybe this therapist wasn’t such a good choice after all.)

I would be remiss if I didn’t write anything about how the therapy sessions function as a plot driver. Anytime a particular activity is used repeatedly, it’s worth determining how it contributes to the plot. In this series each episode except for the first one begins with some interaction with Dr. Timoney; therefore, the therapy sessions are given some importance. The key role each session has is to tell us what the episode will be about;  it drives the action. Another way it operates is to get this couple into the car together and spending at least one uninterrupted hour together. On the other hand, the time spent in therapy substitutes for the more valuable use of time during which they could have talked to each other. Dr. T both creates a space where they can express themselves, something they have trouble doing, and interferes with their ability to relate. If she used the time wisely, she could lead to a greater closeness between them. Finally, like any other outsider, Dr. Timoney brings another character into the village and into Martin and Louisa’s lives. She challenges their preconceptions and unites them, even if it is at her expense.

Alternatively, Dr. T is unknown to the town until she crashes her car; Ruth knows of her but they don’t seem to have interacted much based on their coincidental meeting in the pharmacy in E7; and no one other than Morwenna and Ruth knows that Louisa and Martin are seeing her until she tells Sally after her head injury. This time the outsider stays one. Even her departing scene is exceptional because they make a joke of it, although at least they agree.

All in all, we are given a pretty dim view of therapy. Santa states, “As both Abby and I have said, therapy isn’t really all about the presentation of illuminating, penetrating insights by a therapist, but that is the impression that you get.” Indeed, therapy is depicted as unsuccessful and it is the random thoughts of a variety of characters, many of them dimwitted, who appear to be of more value. The art teacher tells her daughter she loves her as she is; Mrs. T makes a few pointed comments about marriage to ME; and Janice tells Louisa she knows Martin better than anyone. Finally, Mrs. Winton conveys the power of love and commitment despite being in a rather crazed state. The message seems to be to trust in the folksy wisdom of people around you rather than in professionals, a position we wouldn’t expect from a team that has been characterizing Martin, and some other doctors, as professional, highly knowledgeable and capable of saving lives.

(Oh, one last thing…we hear Martin advise patients to seek counseling several times throughout the show and that appears contradictory to how therapy has been handled in S7. What good is it to have someone evaluated if you have very little confidence in the process? I’m not sure what to make of that exactly, but his view that Mrs. Tishell would not have been released unless the professionals were sure that she was under control is certainly disproven. By the end of S7, Sally seems to have arrived at some place of acceptance that Clive is who she should be with, but she never stops stalking Martin and making inappropriate comments to him. The evidence against therapy is stronger than that in favor of it.)

 

Originally posted 2016-08-02 09:05:10.

Professional Opinion v. Folk Wisdom

After writing so much about the poor representation of professional therapy in S7, I want to say something about how Doc Martin weighs in on the reliability of professional advice as opposed to that of all sorts of other people in Portwenn. Part of the problem with making such distinctions is that there could be many reasons why those decisions were made by the powers that be. I think that one very likely reason is that Martin Ellingham’s skills need to be differentiated from the other professionals. His medical knowledge is supposed to appear superior to any other doctor or nurse.  As a result we see him berate and humiliate other doctors and nurses. One reason we may see various residents of Portwenn make comments to him (and Louisa) is that small towns are like that. His neighbors can hear the baby cry or they quickly know about any altercation. Many times Louisa finds out about something Martin did by hearing from someone in town. He’s a prominent person in the town and eventually becomes a part of life in Portwenn. The townspeople begin to offer unsolicited advice as a way to reassure him even when they ought to be aware that he won’t be very appreciative of it. Indeed, that adds to the humor — his general irritation with anyone giving him advice is only further evidence that he is abrasive and unwelcoming. So, we recognize how the advice coming from either professionals or non-professionals works as an integral part of the character development and plot. On the other hand, the preponderance of examples of really clumsy, deficient, and blundering professionals seems to me to demonstrate a bias against professionals. Meanwhile, the number of times we can point to when non-professionals provide insightful and meaningful counseling also gives us pause and makes us wonder if the position of the show is that professionals are suspect and should rarely be respected, and regular folks, the uneducated but replete with life experience types, are the ones to listen to.

The show has included a fairly large number of medical professionals throughout the years, and when you look at them, most are quite incompetent. Among the doctors who can be listed as questionable are Adrian Pitts (S1), Dr. Milligan (S4), Diana Dibbs (S5), Colin Westmore (S6), and the doctor who treats Louisa after her car accident (S6). Adrian is the pits with an even worse bedside manner and attitude than Doc Martin and an insulting treatment of his female coworkers. Dr. Milligan (who may be either a psychiatrist or a psychologist) seems lost and has transgressed patient confidentiality by talking to Edith about Martin and admitting to accepting her suggestions. Diana Dibbs is clearly an anxious mess who abuses drugs, unethically shares her drugs with patients, writes prescriptions without proper examinations, and doesn’t realize she has Cushing’s disease. Colin Westmore is obviously out of his league and much too novice and hesitant for anyone to have confidence in his abilities as a surgeon. The doctor with no name who treats Louisa has neglected to check her adequately and is unaware that she has a DVT, which can be life threatening. (Dr. Timoney in S7 is definitely not a medical doctor; however, like Dr. Milligan, she is quite lacking in therapeutic skills and struggles to deal with marital problems. She eventually divulges confidential information and acts unstable.)

We should put Edith in this category as well because as much as she appears knowledgable about her field, she misses the diagnosis of diverticulitis and would have rushed into unnecessary surgery with little compunction. As we’ve discussed in previous posts, she also unethically asks Louisa about her sex life when gestation age is determined by a woman’s last menstrual period not when she last had sex. In fact, her sleazy demeanor while undermining Louisa to Martin makes her appear petty and disturbingly unscrupulous.

Then there are the other professionals, e.g. the Vicar, the Constable, the Chemist, and the Doctor’s Friend. Most of these are also depicted as compromised in some way. I appreciate the humor, of course, but still it’s hard to overlook the general tendency to denigrate the professionals. The Vicar is a drunkard, both Constables have major hangups: Mark is very insecure while Joe has been phobic and is buffoonish, the Chemist has her Martin obsession and medicates herself to the point of psychosis, and the Doctor’s Friend…well, he’s about as unctuous and repellent as possible. Louisa easily catches him distorting his negative appraisal of Martin with opinions from suspect residents of Portwenn.

In addition, we are presented with a group who we could consider professional, but who occupy a sort of grey area between actual professionals in their fields and pseudo-medical professionals. This list includes people like Sandra Mylow, the Herbalist, Anthony Oakwood, a research psychologist, Janet Sawle, a scientist, Molly O’Brien, the midwife, and Angela Sim, the veterinarian. They are in fields related to medicine and consider themselves qualified to make medical recommendations; however, we find their training and expertise lacking. Sandra earns Martin’s disdain when she willingly provides potions for people she’s never met, not to mention the fact that he considers her type of medical care akin to trickery. Anthony Oakwood is arrogant and his study of psychology is belittled when he excuses his son’s behavior with the jargon of a researcher rather than a parent. He’s the stereotype of a pedant and stunningly out of touch with reality. (We might have thought Martin’s tendency to be engrossed in medical journals and medical terminology could have ended up giving them something in common, but Martin has no respect for this egotistical Ph.D.) Janet Sawle is presented as a mad scientist concocting who knows what in her basement, and Molly O’Brien takes extreme positions about women’s health. Once again she’s a caricature of a midwife with few redeeming characteristics. It doesn’t take long for Louisa to dispense with her once she needs real medical care for a UTI. (There was a point during this scene when I thought “they” were making fun of the serious scenes between Martin and Julie Graham when Julie plays a midwife in William and Mary and gives birth to her baby in a birthing tub.) And, finally, who can take a homeopathic veterinarian seriously? Not only is it patently absurd that anyone can understand dogs by running their hands over their bodies and sensing a deep connection with them, but also she medicates herself with dog medication and becomes hallucinatory. I guess we could say she learned her approach to medicine from her father, who, by the way, is also remembered as mostly incompetent. His best treatment plan was giving Stewart placebos for his PTSD.

All of the above might be considered credentialed in some form and, therefore, people from whom we might expect unsolicited advice. Oddly enough, however, there isn’t much worthwhile advice emanating from the professionals listed above. For the most part the doctors with whom Martin interacts need his advice and have nothing much to say that might help him. The two medical doctors who stand out from this crowd of relative losers are Edith and Ruth. Edith focuses on Martin’s blood phobia and seems determined to rid him of it so that he can move back to London. Her motive Is mostly selfish because she wants to reignite a romance with him; nevertheless, she is helpful in confronting the phobia. What she suggests doesn’t work, but at least she gives it a whirl. She also tries to discourage Martin from losing heart about leaving Portwenn by telling him he’ll feel much better once he gets to London. (Of course this takes place after he has been pretty forthright about not wanting to be with her and she is unwilling to accept that.) Ruth is another matter. As both an aunt and a doctor, she tries to balance her medical advice with personal concern for him. She seems unconvinced at first that marriage is a good choice, although she does what she can to get the marriage off to a good start. She recommends seeking therapy to conquer his blood phobia in S6, does her best to get rid of Margaret, who she knows could only be there to cause trouble, and she continually tries to smooth things with Louisa. In S7 she finds a therapist she believes will be a good fit for him, convinces Louisa to participate in the therapy sessions, and checks in from time to time to see how he’s doing.  Of the medical professionals, she is the only one who offers useful advice even if we later decide that her suggestion of Dr. Timoney turns out to be a bust. Although she says a few contradictory things about whether people can change, I think her best advice comes when Martin is desperate for some guidance after Louisa leaves for Spain. Ruth first asks him if he wants to be with Louisa and then answers his affirmative response by telling him he must change and that he will find that harder to do than most. (Ruth gives others some good advice too. She tells Penhale he can attract more friends by being more complimentary; she tells Al to write his own story and stop delaying; and she tells Margaret to leave Martin alone.)

On the other hand, all of the aforementioned pseudo medical professionals have no qualms about giving advice to Martin. Sandra tells him he should consider doing more for his patients than prescribing medicine. Janet Sawle is suspicious of modern medicines and too many antibiotics, although her reservations are complicated by the uneasy relationship she has with her ailing sister. Molly O’Brien expresses popular concerns to Louisa about the overbearing demands of too many male doctors on their female patients and the hazards of using too many antibiotics. Naturally, her advice to ignore Martin’s recommendation to take antibiotics for Louisa’s UTI backfires and Louisa spikes a fever. (Both the Sawle case and Louisa’s condition point out that the fear of antibiotic resistance is sometimes carried to extremes and there are times when antibiotics are necessary.) Moreover, Molly’s portrayal of women being victimized by their male physicians is particularly offensive to Louisa. She considers herself well equipped to handle Martin and her life. Angela Sim’s advice to Martin mostly arrives through the vehicle of Buddy who she channels as if she is a dog psychic. She tells Martin he and Buddy have unresolved issues. In a scene reminiscent of the one with Sandra Mylow in S2, she also tells him he’s small minded because he can’t think outside the box of routine medical treatments. Later she tells him that “Buddy knows how lonely and unhappy you are, and he wants to help you. You must let him into your life. You need Buddy. You need to accept him.” At this point she starts to appear off-kilter, which could be construed as undercutting her advice. While she’s right that Martin is lonely and unhappy and needs help, hearing that from a dubious source will not have much of an impact on Martin.

But what happens throughout each series is many occasions when we have non-professionals who have no hesitation offering their opinions and advice to either Louisa or Martin. These include relatives, employees, patients, and so-called friends. Some stray townspeople jump into the advice business from time to time as well. Top on the list of non-professionals who have their own notions of what Martin should do is Louisa. Aunt Joan never holds back either. Bert can say some remarkably insightful things. Al, all the receptionists, Roger Fenn, John Slater, Muriel Steel, Danny, both Eleanor and Margaret, Mark Mylow, Peter Cronk, William Newcross, Wallace Flynt all give advice at some point. Even the fish monger, neighbor Mike Chubb, the dry cleaner, and caravan owner Bellamy take a turn. We can’t leave out Pippa, Erica Holbrook and Annie Winton either. In fact, the American Tourist has some words of advice for Martin before she leaves.

Louisa’s advice starts at the intake interview to determine whether they should hire Martin Ellingham as the next GP in Portwenn. Before the interview ends, she warns Martin that the Portwenn community prefers a doctor with a good bedside manner and she will be keeping an eye on him. Along the way she encourages him to have a laugh, to be friendlier to Mark Mylow, more talkative, less smarmy, more proactive, and to say something nice to her from time to time. She also wants him to be more involved with James, more interested in participating in her activities, and more sensitive to his family members, e.g. Ruth’s birthday or Margaret’s visit. Her best advice, in my opinion, is that sometimes people are different and that’s what makes us love them. I also like her advice to Martin when he’s planning to turn in Peter Cronk in S7. She becomes the Louisa we’ve known before and wants Martin to consider the impact Peter’s mistakes have already had on him before bringing in someone who follows the rules so strictly as Penhale often does.

Joan is filled with ideas of how Martin should behave. She’s happy to have him living nearby, but still seems to treat him as if he’s a young boy in her care. Since she’s the mother he never had, he allows her a certain latitude that others don’t have. Therefore, he accepts her criticism, judgements, and encouragement along with her casseroles. She wants him to pursue Louisa only to reach the conclusion that they are “chalk and cheese” and can never get along together. Later, when she finds out Louisa is pregnant and Martin is the father, she expects him to take an active role during the pregnancy despite any resistance from Louisa. She also tells him to remain a part of James’ life even if he leaves for London as planned. And during the broadcast of Louisa’s labor and delivery, it’s Joan who cheers him on to express his love for Louisa. She is disappointed in him when he takes too harsh a stand with patients and uses sarcasm on occasion to correct him when she thinks his behavior is out of line, for example when Helen Pratt dies or when Muriel Steel acts demented or when he insults her friend who caters the concert. Joan is by far the most outspoken of his relatives and quick to comfort him as well as to upbraid him. She certainly makes him think about what his next step should be. Her best advice in my book is telling him a child needs a father even if that father is far away. (Joan gives Al great advice too when he’s troubled by whether Bert is his biological father. She reminds Al that Bert has devoted his life to taking care of Al and whether he’s his biological father or not should not matter. We can speculate all we want about why they have Joan give such insightful comments about fathers — her father was awful, her brother is a rotten father, and she is a woman with a big heart — but her advice sets these two men straight.)

Amongst the best advice on the show for me is that given by Bert in S1E1 when he tells Martin “You need patients and we need a doc. Now we don’t all have to love one another, do we?” That comment makes Martin stop and think, and he changes his mind about leaving. Martin learns about the aged when he takes care of Muriel Steel. She dislikes his condescending manner, puts him in his place, and then comes around to realizing that being at a senior citizens facility is actually quite pleasant. Simultaneously, Joan suggests to Martin that it was her fears that had prompted Muriel’s hesitations about moving, and he seems to learn a lot about growing old. I really like Mark Mylow’s comments when his sister is visiting about being stuck dealing with people we don’t like because they are family. I also enjoy the advice Martin hears from the fish monger after Louisa has left him in S5: “No shame in cooking for one…Nobody cares about me. I might as well sit around all day in my “Y” fronts…You just hang on in there Doc. What’s for you won’t go by you.” Again, Martin gives that some thought.

The conversation Martin overhears between Pauline and Al about another couple that “he’s too shy; he’s always waiting for the girl to make the move. He’s always waiting for permission, and when you give him permission, he messes up” functions as advice and leads to Martin changing course with Louisa.

What are we to make of all these sources of advice throughout the show and their place in the storyline? Can we simply dismiss as humorous and irritating the many times when all sorts of people suggest some lesson to be learned to Martin? There are obvious pearls of wisdom mixed in with the random comments we hear. Roger Fenn tells Martin that becoming a parent introduces one to a whole new kind of love; and Erica Holbrook shows him that mothers can adapt and accept their children as they are. Mr. and Mrs. McLynn, Clive and Sally Tishell, and Jim and Annie Winton give us a few good thoughts on commitment and love. When we look back over the 7 series, it’s hard not to come to the conclusion that they are making the point that each of us have life experiences that teach us more than any insights we can learn from professionals. After surveying the characters from all 7 series, the evidence seems pretty clear that the doctors come out badly. With the exception of Martin and Ruth Ellingham, the doctors give deficient to awful advice, have generally terrible attitudes towards their patients, and are treated as inexperienced and often poorly trained.

Expert advice isn’t always reliable and over time the experts reassess and may change their positions. However, if the expert advice tends to be given by inferior figures, we can’t really consider that a fair representation. Homespun wisdom isn’t always wrong either, but I balk at a 26 year old woman who has been married 3 times already guiding Louisa in any way. It’s funny, but once again undercuts the show’s generally positive appraisal of lay people’s advice.

If nothing else, this exercise has given me a reason to recap some of my favorite dialogue. I’m sure I’ve missed some of the moments you’ve liked the most. I look forward to hearing from you on this topic.

Originally posted 2016-03-03 18:12:38.

Aliens

S7E7 includes an invasion of outsiders to Portwenn. There’s Erica Holbrooke and daughter Bernadette, the new art teacher and her daughter; Inspector Salter looking to switch Penhale to a new, larger location; the American tourist who’s played by Sigourney Weaver, alien extraordinaire; the Wintons, whom we’ve never seen before, and intrude into Martin’s space; and, most importantly, Dr. Rachel Timoney, who previously has never shown her face in the village. (Perhaps all of her patients have been word of mouth.) Each of these newcomers disrupts the normal order of things, and that’s the point.

What is an alien but someone who is not normally seen in a certain setting. And this episode spends a significant amount of time asking us to think about the concept of normality. To a great extent normal is defined by what’s abnormal in regards to where we are situated, and the definition is constantly changing. When Louisa asks Dr. T if struggling is a normal part of the process, Dr. T answers “normal is a loaded word” and that is an understatement. Each community has its own norms, and every social setting does too.  Dr. T might have answered that many, if not most, couples go through various trials before they arrive at a place where they are comfortable with where their marriage is. Therefore, it is normal to struggle for a time. Instead she makes a point of mentioning that the term “normal” has strong emotional implications. Moreover, in “Doc Martin” normal is a loaded word due to the many quirky people we’ve come across, not the least of whom is Martin Ellingham.

In this show, we have accepted that Martin is different, or not normal by the standards used by most of us. He is rude, abrasive, and confrontational to most people. He has a tendency to say what’s on his mind no matter what the setting, which means he has no concern about insulting people. If he’s served canapés, he sees no reason not to note that they are “salmonella en croute,” and when Bernadette is practicing the violin, he gives a blunt appraisal of her ability, which is that listening to her play is excruciating and what she’s playing is not music. We have come to expect Martin not to conform to how most of us have been taught to behave, and we usually enjoy his peccadilloes.

Because his alternative behavior can offend Louisa, he has tried at times to modify his behavior, but he’s typically unsuccessful at doing that. Furthermore, she notices when he’s being artificially nice and finds it transparent and unnatural. In this series, he’s once again doing his best to show Louisa how much effort he’s making to accommodate her. So far his adjustments have done very little to convince her that they should reconcile, and we can see that he is troubled by this. It’s possible that he thought she would come around much sooner once she noticed his determination to set things right, but she is being steadfast in her decision to take her time before yielding. In E7 she once again sends him on his way without so much as a nod to his routine of putting James Henry to bed at night.

Besides Martin both Bernadette and Penhale are identified as different, or abnormal. Bernie’s mother considers her gifted in many areas and has separated her from her peers. Erica is prone to actively pursuing the unusual and her art classes reflect that. Louisa wants her to have the kids do “normal” art like landscapes and drawings of rainbows while Erica asks the students to “confront who we are as people” and express their true selves by mounting their beloved stuffed animals and dolls on a display board. She upsets the children and her daughter by imposing an exercise on them and asking them to give up what comforts them. It seems they all have formed attachments to comforting objects and, therefore, it is “normal” for them to hate being separated from them.

Penhale stands out from the norm because Portwenn has been crime free while he’s been on duty. We know that he has done very little to produce that outcome, and, if anything, he’s wanted something criminal to take place under his watch, but his record looks outlandishly perfect to his superiors. Would he be able to reproduce that outcome if he were to move to the larger city of Exeter? Our suspicion is no. His unusual results are based on the size and character of Portwenn and not on his expertise.

Nevertheless, Inspector Salter notes that the men on the 5th floor want to know who is 3021. And Erica wants to know who these children are. And Martin and Louisa want to know who they are and how they can reconnect. Even Bert wants to find his true identity.

Of course, our American tourist is out of place in Portwenn. She also adds to her alien nature by being manipulative, demanding, and too convinced of her own knowledge. She is impatient and wants her glaucoma drops immediately, then she questions Martin’s decision to examine her only to find out that her doctor prescribed the wrong medicine for someone with her symptoms. Even as a patient she’s different. Her decision to give Morwenna a book about being assertive as a woman reflects her own behavior and can be seen as an effort to change Morwenna.

The fact that there is no real “normal,” begs the question of how to judge what we should change. Not only does our concept of normality change, but also we need to know ourselves, as Erica implies. We need to revisit the idea of whether people can change, but for now, a hint about that is the words that are printed on the art class board: “We Are What We Are.”

The other thing I would say about this episode is that its title, “Facta Non Verba,” is, to me, hard to apply to this episode. Translated from the latin this phrase means “Deeds not Words” or can be interpreted as “Actions Speak Louder Than Words.” But, instead, this episode elevates words to a status above actions, and much of the episode accentuates the importance of words. During the opening therapy session Dr. T asks Martin and Louisa to create lists, to write down what they consider good about being apart. Later she tells Martin that it is the act of thinking and writing the lists that is important. Their final interaction with her has them engaging in wordplay with Dr. T writing down the words they suggest. She also tells them that she’s both “all” and “right.” Isn’t this another reference to how we use these words, and to the ambiguity of words?

At the pharmacy Dr. T loses track of what she’s saying and she calls Ruth senile. Ruth corrects her, telling her she’s not senile, and we can probably guess that Rachel really meant to use a different word, perhaps senior. Rachel also has a fairly nonsensical talk with Penhale whose closing remarks are that her words have helped him by giving him someone who can relate to what he’s feeling. Words can have a powerful impact.

Finally I think it’s worth looking at the lyrics of “Should I Stay or Should I Go,” the song mentioned by Penhale while talking to Martin about whether he should take the job offer in Exeter. (As an aside, this song was written by The Clash, a punk rock band from the late 70s, early 80s.) The words sung by The Clash seem to be right on the mark for this episode. The last scene has Martin telling Louisa that he can’t live like this anymore and she turns to go into the house with a lot to think about.

Here are the lyrics to the song:

Darlin’ you got to let me know
Should I stay or should I go?
If you say that you are mine
I’ll be here ’til the end of time
So you got to let me know
Should I stay or should I go?

It’s always tease tease tease
You’re happy when I’m on my knees
One day is fine and next is black
So if you want me off your back
Well come on an’ let me know
Should I Stay or should I go?

Should I stay or should I go now?
Should I stay or should I go now?
If I go there will be trouble
An’ if I stay it will be double
So come on and let me know

This indecision’s buggin’ me
If you don’t want me, set me free
Exactly whom I’m supposed to be
Don’t you know which clothes even fit me?
Come on and let me know
Should I cool it or should I blow?

Split

Should I stay or should I go now?
Should I stay or should I go now?
If I go there will be trouble
And if I stay it will be double
So you gotta let me know
Should I cool it or should I blow?
Should I stay or should I go now?
If I go there will be trouble
And if I stay there will be double
So you gotta let me know
Should I stay or should I go

 

 

 

Originally posted 2015-11-10 18:16:29.

Attached to Feeling Ineffectual

Since I have obviously run out of personally generated ideas, and the NYTimes seems to regularly publish articles that I find relevant to the show, I hope you don’t mind if I continue to refer to what I’ve read.

The Times has been publishing a series of articles called “Couch” that “features essays by psychotherapists, patients and others about the experience of therapy — psychoanalysis, cognitive behavioral therapy, group therapy, marriage therapy, hypnotherapy or any other kind of curative talk between people behind closed doors.” That has turned out to be incredibly fortuitous, especially because we have been mentioning all of the above on this blog.

This week the article is written by a psychiatrist in private practice in Cambridge, MA and is about a possible explanation for having little tolerance for risk and choosing known dangers over unknown ones. The patient in the story and Martin Ellingham have one thing in common: his father is a brilliant, larger-than-life figure who bullied and belittled him. In the patient’s case, he has continued to try to impress his father. When, at last, this patient’s father and he decide to work together on a business venture, he continues to feel disparaged or ignored until their business becomes a success. Oddly, however, it is at this point that the patient feels worse than ever.

The psychiatrist’s assessment is that having success with his father is unknown territory for the patient and that makes him extraordinarily frightened. “What if he lets himself taste victory and it still fails? There is so much to lose now. Maybe even more terrifying, what if he gets what he wants? Then who would he be? He does not know how to assimilate the identity of successful entrepreneur and worthy son, however much he has coveted it. Doing so would represent a bizarre kind of loss: That is not who he has known himself to be.”

Here’s another way of looking at ME and his achievement of marriage to the woman he has pursued for so long. Is ME now overtaken by fear because he has married Louisa and there’s so much to lose if he fails? Furthermore, having a successful love life is alien to him despite having coveted it for a long time, and now he may be having an identity crisis. He wants to change and has wanted to for a long time, but, faced with having reached such an exceptionally desirable state, he’s not sure how to handle it. He is not who he has known himself to be.

In conclusion, the psychiatrist writing the article boldly states: “We are all afraid of acquiring what we can so easily lose, whether professional status or someone to love. We are caught in a dilemma. Pursuing these commitments can be terrifying. But letting ourselves ignore them can be dangerous, even fatal.” Although I’d like to think that many of us can withstand the sense of accomplishment that comes with success in an important chapter of one’s life, I have to agree that these kinds of major adjustments are accompanied by trepidation. In the case of ME, he has allowed himself to be vulnerable because of his supreme love of Louisa. He might find it very anxiety provoking, even to the point of putting him into a dangerous depression, but his decision to follow her and to work on their marriage should take him out of the danger zone.

Success has immobilized him for quite a while; hopefully he will be rescued from the edge of the abyss by his own efforts to accept this change and by discovering Louisa needs him as much as he needs her. It’s her turn to reach down and grab him as he’s falling. (Sorry, sometimes I get carried away.)

Originally posted 2015-03-15 15:50:42.

NHS News

The following is something I have been thinking about for a while and decided it was time to put it on the blog. It’s not nearly as exciting as some of our other topics, but I think it’s relevant. So here goes:

I am very interested in what’s going on in the UK with their National Health Service for two reasons. I want to understand it better to be able to judge its role in “Doc Martin” and because I want to know how it compares to our health care in the US. I read the BBC News every day for many reasons and I’ve been collecting articles about the NHS. Before I lose track of all the articles, I wanted to post them and make some comments about them.

The way I propose to list these articles is not in chronological order, but in order of significance based on how their content affects health care and can be a reflection of what we see on DM.

The first article was published recently (Nov.) and refers to at risk GP surgeries. Ever since the “doctor’s friend” showed up in Portwenn, I’ve wondered how GPs are monitored. This article makes clear that there is a Care Quality Commission that is a watchdog that pays attention to how patients are treated. According to the article “the CQC look at whether surgeries are safe, effective, caring, responsive, and well-led.” Thus, Gavin Peters was properly looking into the GP in Portwenn following some complaints, and ME was performing all his duties correctly with the possible exception of the “caring” part. As they say in the article, “‘it is only when we inspect we can determine if a practice provides safe, high-quality and compassionate care,'” said CQC chief inspector of general practice Prof Steve Field.” Compassion is the question in ME’s surgery. It’s not clear if ME ever took that course Peters recommended. But it’s clear that caring and compassion are considered essential ingredients to good health care in UK. (Of course, I think we can all agree that those sentiments are important to good care here too. Not only do we prefer to be treated with compassion, but also there have been studies that demonstrate the value of compassionate care by doctors on the outcome of their treatment, e.g. http://www.psychologytoday.com/blog/the-joy-giving/201107/compassionate-medical-care-benefits-professionals-patients-students-and-3)

Another article notes a small number of GP practices have been getting complaints and the CQC has ranked all GP surgeries based on risk of providing poor care. And there has been an increase in complaints made about NHS care, according to this article. Then there is the concern that GPs may be missing diagnoses of lung cancer as a result of not having the proper tools. This article also blames patients for not seeking medical care in a timely fashion. I can imagine that how welcoming the GP is towards his/her patients would be a factor here. There is some tightrope line that must be walked between making sure patients who make appointments are the ones who have valid complaints and patients who need to be seen don’t neglect to come in. On the other hand, there is also a move to punish doctors more harshly for making mistakes, according to this article. In one case reported by the BBC, a doctor was sacked because of substandard care.

In a related article, there is a discussion of how many GPs will be retiring soon, leaving the remaining GPs to take care of more patients. In addition, there is a shortage of GPs entering the medical profession and this article mentions that the NHS needs to increase spending on training GPs and more GPs will need to be recruited. If ME decides to return to doing surgery, finding a new GP for Portwenn might not be so easy. Also, as an adjunct to the first article, the CQC may not have many options when it comes to demanding more compassion from Martin; they may just have to be content that he has so many of the other qualities.

Surgeons are not immune to oversight by the NHS and one article reports that they must publish their mortality rates or be sanctioned.

Not surprisingly, the NHS has some money problems and, according to this article increased funding is something that’s been requested. In October there was a strike by health care workers demanding more pay.

The systems of health care are quite different between the UK and US, yet UK is struggling with many of the same issues we have here in US. The show hasn’t done much with these problems, although I remember Pauline thinking she should get paid more because she was now a phlebotomist as well as a receptionist. Also, like the UK, the US is seeing a shortage of physicians and it’s a concern in terms of access to care, see this article for one. The other thing that we see in DM that is of interest is the procedure for registering with a GP in UK. The GP is usually associated with your postal code and the length of time you plan to be a resident in said location. The minimum stay is 3 months to qualify to register with a GP. New patients can be rejected if the GP is not accepting new patients. In US physicians may consider their practices full too and be unable to take on new patients, but there are no residency requirements. In DM there have been a few occasions when new patients have visited Dr. Ellingham to register, e.g. Julie, the Oakwoods, and it seems they have departed before being residents for 3 months. I’m not sure what actually would have happened with their registration.  All of the above provides some opportunity for a secondary storyline.

 

 

 

 

Originally posted 2014-12-13 13:02:47.

Dr. Martin Ellingham, patient

The following is an intake assessment of Dr. Martin Ellingham completed as if he were a new patient seeking therapy. It was written by Santa, a retired counselor, with input and advice from Abby, currently practicing as a therapist. I contributed to some degree, mostly by asking questions and getting clarifications. I think you will all find this quite enlightening. Santa exposes many insightful details about ME as her assessment summarizes all that we have learned about Martin Ellingham relevant to what a therapist would want to know. As she has told me, she is impressed with how many personal details the show writers have provided from Martin’s life throughout the 6 series. I am convinced that her efforts will inspire much discussion. I invite any other readers of this blog to add observations of their own.

This initial analysis is meant to provide a basis upon which to elicit various treatment protocols and approaches to therapy for this “patient” from any of you who might venture to recommend them. We are interested in any treatment plans you might like to suggest.

As you will notice, we have included medication in his care. We figured Ruth would be likely to refer Martin to a psychiatrist and that he would prefer to be seen by an MD. Most psychiatrists would recommend medicines. On the other hand, we consider it important that therapy include establishing a relationship with someone who is competent in many sorts of therapeutic methods. Santa and Abby believe Martin would benefit from individual therapy as well as couples therapy with Louisa. Of course, we have no idea how the show will handle therapy in series 7, but since there are only 8 episodes in each series, we expect that couples counseling may be all we see.

Presenting Problem:  Martin Ellingham, M.D.  was referred by Ruth Ellingham, M.D. (his aunt).  Dr. Ellingham says that he has sought help because his wife of 6 months has recently told him that she is not happy in their marriage and needs to take “a break.”  She told him this shortly after she had a serious accident, which patient believes he was instrumental in causing.  She was in fact on her way to Spain with their 9 month old son, to visit her mother for an undetermined period of time, when she was forced to return to Truro for emergency surgery to correct a potentially life threatening arteriovenous malformation.  The threat of losing his marriage is a source of deep distress for Dr. Ellingham. He acknowledges that he must “change” in order for their marriage to succeed.   However, his desire to change is not very specific and he is uncertain about how to proceed and what he needs to do in order to be “a better husband.”

He further states that for some time before his wife indicated her unhappiness with the marriage, he had been preoccupied with worries about his health, precipitated by a return of a hemophobia.  He had lost his appetite and was sleeping poorly.  He tried to self-diagnose a physical disorder that might be causing these somatic symptoms; he did not consult a physician.  He also reports increased irritability and decreased libido during this period.   He states that he “shut out” his wife from these concerns, although he can’t explain why he did so.  He believes this to be one source of his wife’s unhappiness and frustration with him. Furthermore, he states that he has never understood why she was attracted to “someone like me.”  He now acknowledges that these somatic issues may have an emotional origin and is interested in exploring issues in his family of origin that may relate to his present difficulties, especially as they may relate to his wife’s decision to take a break from their marriage.   He denies that the return of his phobia has anything to do with his marriage, stating that he loves his wife and son very much.  He reluctantly admits, however, that the chaos and disorder attendant upon life with an infant, as well as sharing his living space for the first time, and with someone who doesn’t share his habits of tidiness, sometimes have been difficult to deal with.    He says that he has been eating and sleeping a little better since he made the conscious decision to seek help in order to “change.”  He admits to being “very sad” from time to time at the prospect of being separated from his wife and son.

Mental Status, Affect and Mood:  Dr. Ellingham is a tall, immaculately groomed Caucasian man, formally dressed, in his late 40s, who appears to be his stated age. His clothes are somewhat loose and he says that he has lost weight.  His affect is restricted, and his mood is somewhat dysphoric. He denies suicidal ideation.   He shows no evidence of a thought disorder; he is oriented and his judgment is unimpaired.  He makes good eye contact and is responsive.  His answers are concise and to the point.   His insight into his difficulties is somewhat limited.  During the interview, he occasionally appeared anxious or irritated, or sad, but these emotions were quickly suppressed.

Substance Use:  Patient states that he disapproves of liquor and never drinks.  He has never smoked, or used any banned substances.

Relevant Psycho-Social History:  Dr. Ellingham is currently a General Practitioner in Portwenn, Cornwall.  Formerly, he was a surgeon in London, for 12 years head of Vascular Surgery at St. Thomas.   About 5 years ago, he suddenly developed hemophobia, disabling him from the practice of surgery.  He reports that the phobia developed when operating on a patient who he had recently seen interacting with concerned family members.  Their concern and affection for the patient suddenly struck him in a way that was unusual for him.  He was unable to finish the operation or to perform any subsequent operations.   He retrained as a general practitioner, and relocated in Portwenn, a place where he had family (an aunt, since deceased) and had spent time as a boy.  It is unclear why he chose to retrain and relocate rather than to seek treatment for his condition.   About a year ago, he utilized cognitive-behavioral techniques to desensitize himself to the sight and smell of blood.  This succeeded enough that he felt able to apply for and accept a position as surgeon at Imperial Hospital in London.  This position was not taken up, as he decided instead to marry the mother of his child and remain in Portwenn, where she was most comfortable.  He states that he detests Portwenn, and finds dealing with his patients frustrating on account of their unwillingness to follow advice or sound hygienic principles.   He denies, however, that foregoing the opportunity to resume his career as a surgeon, and living in a place that he dislikes, have anything to do with his dysphoric mood or the return of his phobia.

He reports that he did not expect to marry or to have a child, and his relationship with his current wife has been tumultuous, marked by missteps, separations and miscommunication throughout their courtship and in their marriage.   Nevertheless, he states that he is deeply in love with her, and has been since their initial encounter several years ago.  (She is head teacher at the primary school in Portwenn.)  They did not begin living together until after their son was born, and the decision to marry was not made until 3 months after that.

Patient states that this is his first marriage and his first serious relationship since he was in medical school.  His first real relationship  ended when the woman, a fellow student, chose to leave England to study abroad.  He reports that he was devastated by  this.  With few and brief exceptions, he has neither sought nor welcomed female companionship thereafter.  At the same time, he is clear that his orientation is heterosexual.

Social Supports.  He has lived alone all his adult life.  He reports few friendships of any significance, with the exception of a former classmate from medical school, who is now the head of the Cornwall NHS, and who helped him to relocate and later in his effort to find a job in London.  He does admit to being friendly with one or two inhabitants of Portwenn.   He was fond of his aunt, now deceased, who was living in Portwenn when he relocated, and she was a source of support to him both when he moved to Portwenn and as a child.  He is close to another aunt who now lives in Portwenn, and she is perhaps the only person in whom he feels he can confide.   He reports that he has little time for social niceties, which he considers “rubbish,” and always speaks his mind.  He admits that some may find his manner abrasive.  In any case, he feels that finding a friend among the inhabitants of Portwenn is highly unlikely, as he finds most of them extremely irritating.  He has no church affiliation. His sole hobby is repairing antique clocks, an activity that he does alone. His wife does not share this interest.

Family of Origin Issues:  Patient reports a long-standing estrangement from both parents.   He had no communication with them at all for seven years, until a couple of years ago, when they showed up to ask for money and announce their separation.  During this visit, his mother made clear how much she had always resented and disliked him, to the point of saying that she wished he had never been born.  Predictably, the visit ended badly, and he had no further communication with them until a few weeks ago.  At that point, his mother arrived unannounced, and told him that his father had recently died and she had come to re-establish a relationship with him as her sole remaining family.    It developed that she was without financial resources and that  her real goal in contacting him was to obtain from him enough money to support herself.   Upon realizing the extent of her duplicity, Dr. Ellingham asked her to leave his house and indicated that he desired to sever all further relations with her.

Patient’s childhood was marked by bedwetting, social isolation, ridicule and shaming from both parents, little affection, and harsh punishments, including spanking with a belt and enforced enclosure in small spaces for seemingly trivial infractions.  His aunt recently told him that between the ages of 4 and 6, his behavior underwent a change and he became significantly more defended.  He was sent to boarding school from age six on, where he notes that his bedwetting and social isolation continued and he was the object of considerable bullying.  Uncoordinated and physically clumsy, he did not participate in team sports.    He was, however, good at chess and derived some pleasure from winning competitions.

Patient’s father and grandfather were surgeons, and patient seems to have internalized their belief that a surgical career was the top of the medical profession, and that being a GP was far inferior.  His father was contemptuous of his position in Portwenn.

Patient reports that he had only very recently come to understand that he did not deserve his parents’ treatment of him and that, in fact, it was abusive.   He notes the contrast between his childhood, and his wife’s and his own loving interactions with their son.    He wonders if he might possibly have developed a sense that he does not deserve to be treated lovingly.

Summary and Clinical Assessment:  It should be noted that Dr. Ellingham has recently experienced multiple significant stressors, including recent marriage and fatherhood, marital difficulties, death of a parent, and the severing of ties with his mother.   At this point, he certainly meets criteria for a diagnosis of Major Depressive Disorder, with periods of sadness, loss of appetite, difficulty sleeping, loss of interest in usual activities, increased irritability, and feelings of worthlessness, and guilt.  He has agreed to a trial of anti-depressant medication, and medication to help him sleep.

Dr. Ellingham has a specific anxiety disorder, i.e., hemophobia.  The hemophobia is of secondary clinical concern, although it should be addressed at some point, ideally by returning to a course of desensitization, supervised by a cognitive-behavioral therapist to make sure he reaches a point of “overtraining.”

Dr. Ellingham has few interpersonal skills, and little understanding of their utility.  He tends to have little empathy with others, and has lived as a social isolate for most of his life.  He makes good eye contact, however, and his lack of empathy may well be a result of suppressing emotions he considers “soft” rather than an inability to sense the feelings of others.  While a diagnosis on the autism spectrum, i.e., Asperger’s, can be kept in mind, this interviewer does not currently find much support for such a diagnosis

The clinical impression of this interviewer is that Dr. Ellingham is a man of formidable intelligence, who learned very early in his life to formulate a defensive structure that protected his deep sense of vulnerability and defectiveness.  This was necessitated by emotional and physical abuse, but more significantly, a profound failure of maternal attachment.   This defensive structure includes an insistence on order and control, on minimizing affective reactions, and on a degree of autonomy and lack of entanglement in relationships that might expose his neediness and vulnerability.   In short, intimacy presents serious difficulties for him.  He is unable to seek help from others, and because this “counter-dependent” structure emerged so early – certainly by the age of 6 or 7 – he has been unable to manage or integrate emotional responses that occur in later life.  Another way to say this is that much of his emotional development has been frozen at the “child” level.  Thus, “falling in love” was an experience which essentially blind-sided him, and for which he was in no way prepared.   Ultimately, this impulse was too strong for his defensive structure, and he acted on it.   The burden, however, of living intimately with a wife and child and surrendering much of his sense of control, has been another major stressor, under which, this interviewer believes, his anxiety disorder, as well as other somatizing symptoms,  re-emerged.

It is this interviewer’s impression also that his feelings about his loss of his surgical career, both from his hemophobia and the decision to remain in Portwenn, are unresolved and probably contribute to his depression.

Last, there is a hint of some traumatic event between the ages of 4 and 6, which should be explored as the therapeutic alliance becomes stronger and the patient’s symptoms of depression are resolving.

Recommendations:   Dr. Ellingham’s wife, Louisa, should participate in some sessions with the treating therapist.  He has never been able to share much of his inner self with her, and may need support and assistance in doing so.  Helping her to understand his difficulties may go a long way toward healing their marital problems.    Couples counseling is also recommended, if his wife will agree to it.

Nevertheless, Dr. Ellingham could benefit from individual therapy.  He has many losses to grieve, among them the loss of his career (and identification) as a surgeon, and the loss of his parents, both now and as a child.  He needs to repair a sense of himself as defective and undeserving of love.  He certainly needs to develop better access to his own emotional life.   A cognitive-behavioral strategy or “restructuring” negative thoughts would be a good place to start.  The experience of a therapeutic alliance with a treating therapist would be of significant benefit to him.

 

 

Originally posted 2014-12-07 14:34:19.

Louisa’s Difficulties and Martin’s Hand Wounds

After Santa and a few others mentioned the last scene in S6E3 where the camera recedes (a dolly-out shot) as M continues to treat the cut on the palm of his hand, I went back to look at it. Their comments had to do with the camera work accentuating M’s isolation, which I think they are right about. Then I started thinking about how that episode has always bothered me, beginning to end. I have been a staunch defender of Louisa, but if I were to find a time when I think Louisa is depicted as lacking sympathy or sufficient concern for M, it would be in this episode. I want to discuss that and then move on to another pet peeve of mine-whether DM is medically accurate.

The episode begins with loud knocking at the front door before 6:30 a.m. L is annoyed at being awakened so early and stays in bed while M goes downstairs to see who’s at the door. It isn’t long before her alarm rings and the baby starts crying. She didn’t get much more time in bed and I would have expected her to get up with M like she does in S5 when Morwenna shows up too early for work. (I think that time it was only 6 a.m.) When L comes down to see what’s going on, M asks her if she can identify the man who has been dropped off after being found unconscious on the beach. She has never seen the man before and is in a hurry to get James dressed. We can hear James crying upstairs. She, therefore, doesn’t want to get M water for the pt. The look he gives her makes her change her mind. I would have expected her to be willing to help with the water without objection. The next time we see her, she is ready to head out to school and finds many things to express concern about to Michael before she hands him James. Here we have a mother’s difficulty with leaving her baby, while she overlooks her husband’s needs. We know M has gone upstairs to get dressed, but we don’t know what, if anything, was discussed while they were both getting ready for the day.

By the time L is ready to walk out the door, M has confronted his blood phobia’s return. L notices something is up with M, but ignores it and leaves for work. (This may not be surprising since he looks like he’s deep in thought and he isn’t much for affectionate goodbyes.) They’re really both on edge, for different reasons.

As the day continues, L is distracted by mixed feelings about leaving JH and doesn’t read Becky’s article for the newspaper. The next day she gets angry with Becky over publishing it without her permission. She’s still bothered by leaving JH with Michael. Thus, work is stressful at the same time as L is stressed by her dual roles and M can only say “I told you so.” We should give her some space for dealing with so many stresses.

The following day begins with Ruth visiting and finding M rocking JH because they had a bad night. Of course, lack of sleep puts additional stress on both parents. The day turns out to be trying in many ways with L dealing with Bert’s anger over Becky’s article and M dealing with the recurrence of his hemophobia and then rescuing Ruth from her stalker and getting his hand cut.

By the last scene, L has learned of M’s scuffle with the stalker at R’s house and says, “what a day!” She sees him cleaning his wound, and asks how his hand is. She’s not satisfied and asks again if he’s all right. He covers up by asking her about her day and putting some gauze over his wound, keeping it covered from L. L tells him about how she’s handled the Becky matter. It would be a nice exchange between them if it weren’t for the hand issue. L tells him he looks pale, but reads Becky’s article about him anyway, asks if he’s really ok, then leaves him. Of course, he says he’s fine; he says that every time. But I had to wonder why L would read an article to him that criticizes him just when he’s dealing with a wound after a long, tedious day? They first agree that Becky has a right to free speech, but it’s rather harsh to read a critical article about M at that moment. If it’s meant to be funny, the joke falls flat, including L’s judgment that Becky’s only ten and has written this piece well.

Louisa at least has a mixture of concern and lack of concern. She always meets with his resistance to tell her very much, and that can’t be easy. So I give her a less than satisfactory assessment during this episode even though she can’t be faulted entirely.

Then I started thinking about all the times M has wounded a hand and how difficult that would be for a surgeon. Their hands are exceptionally important to them.
S2: Martin gets his wrist caught in a trap while looking for Mark in the woods
S4: falls and hurts hand on broken glass
S6: hurts wrist falling down a hill in E1
gets his palm sliced by large knife during scuffle in E3

Hand wounds are often quite painful and this last one should have been. I also think it should have been looked at in the ER and L should have insisted on taking him there. Most doctors think they can take care of their own medical problems only to find out they need help. (I know because I’m married to one of those! Don’t bother a colleague-it’s embarrassing.)

In the above episode there are several medical and logical instances that are not very accurately presented. Not only does Martin seem to have a clean gauze bandage handy in his pocket to wrap around his bleeding hand immediately after it is cut, the knife isn’t dripping from blood after the event. Martin seems to have a high pain threshold throughout the series, and in this case he would have to because palms of hands have a lot of nerve endings. Following the altercation, he offers to make Ruth a cup of tea to calm her, which means he must feel good enough to not deal with his hand immediately. We also have to assume the cut wasn’t very deep because he can move his fingers and the wound stops bleeding pretty fast. Also, Martin had to have held his hand so perfectly following the cut, and the cut must have been rather shallow, or the skin would not have been aligned as well as it looks in the final scene, nor would the edges have adhered to each other so well. Furthermore, all surgeons are very alarmed by any injury to their hands. Surgeons sometimes joke that they are all cerebellum, brainstem and hands. At the beginning of S6E4, Martin no longer has a bandage on his left hand and he can hold the baby without a problem. We don’t know exactly how much time has elapsed between these two episodes, but unless it’s at least a week later, it would be surprising for him to not have it bandaged anymore. In S4, his phobia kept him from even looking at his wound and he kept the bandage on for quite a while.

In addition, Ruth gives Robert an injection of either Largactil or Benzodiazepine. She suggests either to Martin, and we’re not sure which one he has in his bag. Both of these meds are used to treat all sorts of psychiatric disorders related to psychosis, anxiety, schizophrenia, etc. Neither would be likely to work so fast that the patient would collapse on the floor immediately following an intramuscular injection of it. It would be more likely to take a minimum of 5 minutes rather than 10 seconds to take effect. For the purposes of the show, the medicine has to work fast, but it’s not accurate.

There is always a spectrum of plausible to possible to likely in every medical condition. Naturally there are individual differences for everything too. But I think the accuracy of the medical cases in this show is very much along the lines of what Philippa says in one interview: they ask the medical consultant if something they’ve come up with is possible and if he says it is, they leave it in. The medical accuracy in this show is better than most yet still not really that stringent.

Originally posted 2014-05-22 17:23:25.

Martin’s mistaken and missed diagnoses

ME is a great diagnostician and recognizes esoteric syndromes fairly frequently, and we generally come away with the notion that his diagnostic skills are exceptionally good. Nonetheless, sometimes he gets a diagnosis wrong or misses it entirely. No doctor can diagnose everything correctly, but he is loathe to admit a mistake of any kind. In this he is not all that different from most doctors in general who can sometimes go off in the wrong direction and even have blinders on when it comes to certain medical conditions. When ME gets a diagnosis wrong, though, he blusters and blames others rather then accept his mistakes. Let’s see how many of the mistaken diagnoses I can come up with:

Water contamination source, not pool and not the village water service but Bert’s bottled water. Later his dishwasher is the cause of stomach problems in the village. There are contaminants due to his having hooked up the dishwasher incorrectly, but he blames the young substitute receptionist for serving tea to his patients.

Peter Cronk’s injury following fall. He dismisses Peter’s abdominal discomfort and Louisa’s concern as overreacting. When it turns out that Peter becomes very ill and Louisa calls him in the middle of the night to come to the Cronk house, he realizes Peter’s spleen has probably ruptured. This time he starts to apologize but gets cut off by police arriving.

Danny Steel’s mother’s dementia turns out to be dehydration. At first ME suspects nothing wrong and figures Danny is overreacting just to place his mother in a home. Once she’s in the home, he notices that she hasn’t been taking her medicine and that she resists drinking fluids at night.

The students at school come down with what looks like impetigo to ME and he wants them all to stay home because it’s very contagious. It turns out to be erysipelas instead, which is not contagious.

Old man (Mr. Cook?) with stench doesn’t have a hygiene or health problem, he has a dead bird in his bag. (Surprising that Martin doesn’t check the bag that the man carries with him at all times.)

Caroline doesn’t have a drinking problem, she has diabetes; Dennis doesn’t have a drinking problem, he has Parkinson’s. Both of them slur their words and have trouble driving properly, but the suspicion that they have been drinking to excess is wrong. ME treats them properly once he knows what the problem is, but never apologizes for assuming they were over-imbibing.

Phil Pratt’s wife Helen. She’s much sicker than he suspects and he doesn’t notice her labored breathing, her diaphoresis (or perspiring), or weakness because he’s irate that he’s had to make a housecall and he’s irritated about Louisa’s relationship with Danny. Helen dies while he’s calling an ambulance and he compounds his rather restrained reaction to her condition by having very little compassion for her husband. When Joan arrives and tries to smooth things over, M still shows no sympathy.

Mrs. T’s neck and her need to use a cervical collar. When she takes it off, it turns out she has a prolapsed disk problem. He also misses her Erotomania and falsely accuses Louisa of having it.

Delph, Allison’s daughter acts out of control, but ME just thinks she’s naughty. Finally, after Delph takes a nasty fall through the glass door of a shop, ME realizes there’s something very real wrong with her. It turns out she’s really hyper due to diet pills.

Mrs. Selkirk is mourning the loss of her husband and hallucinates that he’s talking to her. ME assumes her hallucinations are due to grieving, but later discovers she has Lyme disease and that accounts for her symptoms.

At one point, ME examines a man for testicular problems. This mistake is due to examining the wrong patient because he’s been given the wrong notes. Even though it’s Pauline’s mistake, he should have checked the name.

Al has gone to Uganda and had a terrible trip. He can’t seem to shake the fatigue and difficulty getting back to a normal routine. He talks to ME about it but ME considers his symptoms inconsequential. Then Al faints and ME discovers he’s been bitten by a tsetse fly and probably gotten East African sleeping sickness.

Woman has swollen ankles and dark complexion with joint aches. ME thinks she’s been spending too much time outside, but it turns out she has too much iron in her system.

Mr. Moysey is having a variety of symptoms including dizziness. When he comes to the surgery to get his prescription refilled, he has a bloody nose. He gets his prescription although ME does a cursory exam. He returns after having more symptoms but ME still isn’t concerned. Ultimately Mr. Moysey falls in his home and Ruth calls Martin. Now he finds skin lesions when he opens Mr. M’s shirt and realizes he has scurvy from following a diet low in nutrition since his wife died.

Malcolm, a hypochondriac, complains of skin problems and seems to be breathing poorly. ME suspects possible asbestosis, although because Malcolm is a hypochondriac it’s easy to dismiss his complaints. Asbestos poisoning is eventually ruled out and, when Malcolm uncharacteristically misses an appointment, Morwenna finds him blacked out in his yard. It turns out that Malcolm keeps pigeons, which everyone except ME seems to know about, and he has gotten pigeon fancier’s lung from the fecal matter.

Then, in the last episode, ME vaccinates a woman for rabies, although she complains of headaches. We might forgive him for being distracted and not paying proper attention to her since Louisa is getting ready to leave; however, when he realizes his mistake, he is not apologetic. He tells her she should be all right and may experience some nausea and other symptoms. But she should be fine. She finds this poor consolation.

If I’ve missed any other examples, I’m counting on anyone reading this to help me out. I wanted to review these mistakes because it’s so easy to merely think of ME as a “wonderful doctor” and forget the times when he goes awry. I’m glad these examples are included because it keeps things much more real. Luckily, most of the patients end up doing well after these missed diagnoses, with the notable exception of Helen Pratt. (Truth be told, Martin probably would not have been able to save her even if he had tried to do something. Still, trying would have meant something to Phil.) It would be nice to think that happens in the real world too. In addition, ME clearly hates to be wrong and has a problem admitting when he’s wrong. Showing sympathy is also hard for him. Most of the time his lack of sympathy is funny. On the other hand, when there is evidence of honest sympathy, it has more significance. This is true for the times when he admits that he’s been wrong as well.

Originally posted 2014-03-13 20:42:24.

Class differences in UK

Previously on this blog there have been comments about how the relationship between Martin and Louisa should also take into account the difference in their class status. Veronica noted that in England it might be unusual for a person from Martin’s background to fall in love with and marry a person from Louisa’s background because of their class differences. She used the naming process as an example: When they leave the hospital and Louisa mentions calling the baby Terry after her father,Martin thinks the name Terry is too common. He covers his first comment by saying “I mean too many Terrys already?” trying to make it sound like he means it’s too often used rather than it’s not of high enough status.

When they go out to dinner to discuss the baby’s name (S5E5), Martin mentions he’d like to use Henry, his grandfather’s name, and that his grandfather was an accomplished physician. Louisa counters that her grandfather’s name, James, would be her choice and that he was a postman. She appears defensive about that and tells Martin the fact that her grandfather was a postman doesn’t make his choice more valid. For his part, Martin denies he was making any judgement about status, but the issue is out there.

During the course of the series there have been comments by villagers about Martin’s suits. His suits function in so many ways that I hadn’t given much thought to how they would also be a symbol of class distinction. But it’s certainly true that there isn’t any other villager who regularly wears a suit. Penhale, and the other police officers, wear uniforms and that sets them apart from the people in town, but most of the town dresses casually on a daily basis. That’s not really so different from most towns, although Portwenn has no evident lawyer, banker, or corporation that might include others dressed in more formal attire.(Actually, Tom, Caroline’s husband, has a coat and tie on in the episode where he appears.)

I mentioned in my entry about myself that my husband practiced neurology in a small town. One of the amusing things about some of the doctors there was that a few liked to walk around town with their white coats on. Sometimes they’d go to the post office or other places in the village with scrubs under white coats, or just the white coats over a nice shirt and pants. We always thought they looked ridiculous and were trying to impress people.

In our experience in the medical profession, some hospitals expect the medical students and doctors to wear ties and white jackets or coats, some do not, and some of these practices have changed over the years. We see some of that when Peter Cronk gets taken to the hospital and those doctors are wearing ties or dressy clothes. The Mayo Clinic in Minnesota requires its doctors to wear jackets and ties as a sign of respect for the patients. So for Martin as the GP to wear a suit wasn’t so remarkable to me. (I know it’s also used as an indicator of being uptight, closed off, oriented toward ritual, etc.) But I have to admit, wearing a suit also sets him apart and above the villagers.

I have to say that Louisa, too, often dresses more nicely than her colleagues or most of the other villagers. Because of that, she seems more likely to be a woman Martin would find appealing, but it also sets her apart to a certain extent. We do see her in jeans at times, though, and that connects her to the community.

Of course, it is their altercation over schools that causes a big brouhaha in their marriage. Martin is already interested in signing JH up for a boarding school, but Louisa is totally against it and can’t believe Martin would be thinking already about sending JH away when he’s still such a young baby. She’s upset for more than class reasons — she’s the headmistress of the school and considers the school fine for a good education. After all, she was educated there and went to college in London. But Martin wants to give JH the best education available.

This argument is consistently a part of US education discussions. Are our public schools giving our children a sufficiently good education? Do parents need to send their children to expensive private schools, boarding or otherwise, to get them a quality education?

I really hadn’t thought too much about this concern in terms of UK and this show until I saw an article by the associated press recently that reported:

“In most areas of British life, success comes down to going to the right — usually expensive — school.

A third of Britain’s lawmakers, half its senior doctors and more than two-thirds of its High Court judges went to private schools, which educate just 7 percent of British children, according to statistics compiled by the British Parliament. Well more than a third of Oxbridge undergraduates still come from these private schools.”

So it looks like the show actually is making an accurate point about the importance of going to an elite school that will lead to a high-status career. The conflict is not just a good way to put Martin and Louisa at odds, especially about something that is her profession.

There’s also the matter of whether Louisa should return to work now that she has a baby. Martin doesn’t want Louisa to work, a sign that he makes enough money to support them both and that he’s still thinking like old-fashioned elite men who want their wives to be home with the children. He gets a lot of blowback on that from Louisa throughout series 5 and into series 6.

We also know that Martin’s parents consider his move to Portwenn to be the GP a definite step down for him.

More than I originally realized, it seems like class and its importance in the UK is a factor in this series.

Originally posted 2014-02-12 16:25:00.