An entertaining and thought-provoking talk by a specialist in Endocrinology, describing experiences in his career in medicine (with some excellent advice!), and giving some illustrative case histories.
Prof Manning described himself as a physician with an interest in endocrinology, who is also a Professor at the School of Medicine. He grew up in Auckland, and was the youngest of three, his older siblings having both gone into law, “So I think my parents decided there were enough lawyers in the family, ‘Why don’t we see if we can snag a doctor?’ - so I duly applied for Medical School.”
Up to that point his only contacts with medicine had been seeing the family GP occasionally. “In those days it was quite austere. He wore a white coat - but he was quite a nice fellow, and he was doing a lot of good, and was well respected.” Possibly the most significant event stemmed from the fact that GPs did house calls in those days, and one day Patrick’s father was unwell, and "The doctor came in, and he did something - I don’t know what it was - but my father was miraculously better. I think he just gave him an inhaler for his asthma, or something, but I thought . . ‘This is pretty impressive! This guy is God-like almost!'”
In those days one applied to go to Medical School from school, which he did at the age of “16 or 17” , and took the Bursary exam for entry, which he achieved. Applying to both Otago and Auckland, he was offered a place at both, “In the end, it was just too easy to go to Auckland.”
Another factor was that, at Otago, one had to do a year of general papers before starting on Medicine. “It’s a completely different experience going to University in Auckland. I think you guys have got it much better down here, living in this sort of environment.” (Dr Manning’s wife studied physiotherapy at Otago, and was a St Margaret’s resident, and “really enjoyed her time here”).
They have three children, all have gone to a University college while studying here, “just because of the experiences that you get” in such an environment - and all three count it as being a highlight of their university days.
Medical School has changed, with much more clinical integration in the early years. When he was a student, it was not until 4th year that students had any contact with patients, whereas this begins now in second year. Having successfully completed the 5th year exams, he undertook a three month elective in London. “. . . and worked very hard on my elective, not like some of these elective students, who just go away and have a holiday.” Returning to NZ, he started as a House Surgeon at a small hospital in the little town of Thames in the North Island. “It was bizarre - I’d gone from being a trainee intern having really no responsibility to suddenly being a junior doctor, and - when on call at the week-ends for example - being responsible for all the people in the Coromandel Peninsula . . . You saw everything . . It was a huge learning curve . . . wouldn’t happen nowadays.”
Maybe Not Surgery . . .
The rest of his time as a junior doctor was spent in Auckland, and the big decision was whether to specialise or go into GP work. He enjoyed hospital medicine, and decided to stay there, working in several different departments, trying to work out which ones he liked, and which ones he was good at. “I was told fairly early on that I should not be a surgeon.” This happened during an open heart operation, when the patient’s heart had been temporarily stopped, while a heart-lung machine continued vital functions. Dr Manning was invited to cut the sutures to complete the attachment of a pacemaker wire to the heart, but the heart at that point began beating. As the suture began moving around, he was ‘chasing’ it backwards and forwards , repeatedly missing it. “Don’t be a surgeon!” said the thoracic surgeon conducting the operation. “In the kindest possible way,” Patrick told us, adding, “Actually, in those days it wasn’t very kind at all!” He had more or less decided that for himself, having recently married and bought a house, he found that the ‘Home Handyman’ projects he undertook, “and they usually turned out to be disasters.” So he had worked out that manual skills were perhaps not his forte.
The Pursuit for the ‘Right’ Specialism
Having tried several options, he decided on Medicine, which has numerous non-surgical specialisms within it. After a couple of years as a Medical Registrar, you sit “these horrible, horrible exam, called the Part 1 exams which require 6 to 12 months of study. But he found he actually enjoyed learning about the various medical specialities, as “it allowed you to integrate basic science with an understanding of medical illness.” It was during this study that he gravitated towards endocrinology, “It sort of appealed to me and sort of made sense,” and the wide variety of conditions gave added appeal.
Having passed Part 1, which involved both written and clinical exams, Patrick sought a post in the Endocrinology Department at Auckland Hospital, working with four specialists who were all ‘great mentors’, doing research and teaching as well as clinical work. This experience firmed up his desire to specialise in endocrinology.
Qualifying in the subject after a total of 3 years in that Department, he went to London. “I guess that’s where I had my experience of living in a place like this.” This was at Goodenough College, an establishment with an interesting history established mainly as a ‘thank you’ to the Commonwealth countries. - During the Second World War in particular, both Commonwealth countries and the USA sent food parcels to British people, and in recognition of this, the Lord Mayor of London launched a Thanksgiving fund, the proceeds being used to build William Goodenough House, later combined with London House which has a somewhat similar history. [If you are ever thinking of going there, book early, the waiting list is long - Ed.}
It is not free to stay there but is a good deal cheaper than London accommodation generally. While similar in. many respects to St Margaret’s “it was much, much bigger “ with little apartments for families, and single rooms for individuals. There were people from all around the world from Commonwealth countries, and, in the end, it was a fantastic experience, I guess like you are having here. “They put on lots of events.” These included a sweepstake the winners of which had free entry to watch shows from the College’s box at the Royal Albert Hall. They also had a Manor House in Scotland that one could stay at. “A pretty amazing experience.”
Working in London
Patrick worked at the now demolished Middlesex Hospital in London, where the wards were long rooms with perhaps 20 beds down the sides. He travelled there by tube (London underground railway), in a journey requiring changing trains once, taking overall about 45 minutes. One day when he finished early and noticed the weather was good, he decided to walk home - and the journey took 15 minutes! On the Tube there are no landmarks to see, so you cannot tell where you are actually going. From then on he walked every day, enjoying the stroll through central London.
Senior Registrars, as Patrick was, did most of the work, while the eminent, internationally renowned consultants offered the occasional piece of advice. One patient was investigated over a period of several weeks and turned out to have a very rare condition which required an operation - which was highly successful. Patrick suggested to the Consultant concerned that, under the circumstances, it would be good if you were to meet her before she goes. To that point “he had never even seen the patient.” When he agreed, Patrick said he would meet the Consultant on the ward and he could shake her hand. “Just remind me,” the Consultant said,”whereabouts is the ward, again?” “It was very different to the way we practice medicine now.“
The Nature of Endocrinology
After working in London for two years, the plan was to return to Auckland to take up a post as consultant, but the post did not materialise. There was, however, a job at Dunedin, and he applied successfully for that one, planning to move up north after a year or so. “That was nearly 30 years ago. . . Still waiting.” (Short pause). - “No I’m not!”
With the children starting to go to school and making lots of friends, and himself and his wife also making lots of friends, they were enjoying themselves too much here to leave, although opportunities did occur. The work situation was also good. When he began, he was doing general medicine along with endocrinology, but after a few years he concentrated on endocrinology.
“What is endocrinology? It’s disorders of hormone-producing glands, so probably a quarter to a third of what I do is see people with Type 1 diabetes, and some with Type 2 - we obviously can’t see everyone with Type 2 diabetes, because there are so many of them.” In general, endocrinology involves hypoactivity, hyperactivity or tumours of the pituitary, thyroid, adrenal glands and gonads. “There are a lot of other weird and wonderful things that we see as well.”
He also teaches at 3rd year, 4th year - (how to examine patients at the bedside), 5th year students (endocrinology) and there is usually a postgraduate student in the group also. His main research interest is in obesity. Far from being an inert tissue, as once thought, adipose tissue actively produces hormones and cytokines.
Another area of work is in clinical trials. Any possible medication must first go through randomised controlled trials, where even the researchers do not know which subjects have been given the drug, and which given a placebo until all tests are completed. These are generally multi-centre trials involving groups all around the world at the same time. Some of those treatments are now in general use.
In addition, Dr Manning has done some trials of his own, and also does a small amount of private practice. He examines for the College of Physicians in those ‘horrible’ Part 1 exams. mentioned earlier, “Which I now inflict on other people - which is quite fun!”
The Family - and Its Most Important Member
Two of his children have done medicine, one being an oncologist and the other a radiologist. Their youngest has studied Information Technology and Marketing, also getting involved in student politics, becoming the OUSA President. He now works in Parliament working on policy. “I think he’s enjoying himself, probably more than any of us!” Originally a physiotherapist, his wife then became a mother “the most important member of the family, and then decided, when the kids were all at school, that she would go back to university . . . and over some years did a law degree and practised law for about tenyears. At that stage, she decided to look for a new challenge and started up a charity called ‘Kiwi Harvest’. . . .It’s a ‘food rescue’ charity where they get food that would otherwise be thrown away, at supermarkets or cafes, and get it to various organisations such as the Salvation Army . . . And that’s now all round New Zealand. . …..So what you start off doing does not mean necessarily that that is what you will end up doing.” “That doesn’t happen too much in medicine. People have invested so much time in it, usually they don’t throw it off and do something else.”
Question Time - Dealing with Self-doubt, Look Before You Leap, Case Histories
With the session open for questions, Dr Manning was asked at what point in medicine does one start to think ‘This is a lot more intense than I thought it was going to be.” In his response, Dr. Manning said,”Well, you’re only human. The worst people in Medicine are the people who don’t doubt themselves. I come across these people all the time. They are too confident for their ability. You want a confident surgeon - you don’t want someone who is doubting themselves holding a scalpel who is going to do something to you . . with their hand shaking. But you need to have the appropriate level of confidence to your skill. You come across people, far too frequently, who are far too confident for their level of skill. Those sorts of people can harm patients. Unfortunately they sometimes don’t have the self-awareness to realise that that’s what’s happened. . . . . A lot of people who have gone into Medicine are type ‘A’ individuals and they are their own worst enemies, and doubt themselves all the time. It becomes manageable because you see the same conditions over and over again . . . You become comfortable with dealing with a degree of uncertainty so you manage it.” Everyone is different but experience helps one to deal with a degree of uncertainty.”
Another question about the one piece of advice he would give to the future doctor, Dr. Manning said that medicine is changing a good deal, and it’s hard to know what the practice of Medicine is going to be like in 20 years time. “There are going to be so many new treatments, so many new technologies. Bit I think it’s an exciting field to go into . . .It’s great to be in an occupation that’s changing all the time, because it keeps it interesting. Try to keep an open mind. I see so many people going into medicine who say things like, ‘I’m going to be an orthopaedic surgeon’ on the first day of their second year!” What grabs your attention may be something you are not expecting. Try as many areas as you can, and wait for that to happen.
You are much better practicing medicine in an area that you love rather than one you thought you would, without experiencing as much as possible. You are going to be doing it a long time.”
He was then asked about any patients that stood out to him. “Yeah, good and bad! . . .I’ll tell you about a couple.”
The first was a man with an unusual form of overactive thyroid gland, the sort of thing you see maybe once a year. Then in a short time, maybe a month, he saw four more such cases, and felt this was sufficiently strange to contact the public health people. They carried out some investigations, and found: 1) All those affected drank soy milk. 2. The soy milk came from the same source (All lived in Queenstown). 3.”Soy milk is absolutely horrible to drink, unless it’s flavoured with something.” 4. The flavouring used in this case was kelp. 5. Kelp is rich in iodine. 6. Lab investigation showed the soy milk contained about 100,000 times the recommended daily dose of iodine. “The person responsible for flavouring the milk had had a meltdown that day, or something, and put in way, way too much.” In consequence those soy milk drinkers had become thyrotoxic.
Another case involved a lady admitted to the Intensive Care Unit with extremely low blood pressure, along with swelling of her tissues (oedema). She had had three or four earlier admissions of a similar nature over a period of years. Called in because the problem was thought to be due to adrenal gland malfunction, which he quickly discounted, Dr Manning did some research and came across a rare condition called ‘capillary leak syndrome’ which fitted this patient’s signs and symptoms exactly. For whatever reason, the sufferer’s capillaries become leaky so that fluid moves from the circulation into the tissues, causing both oedema and blood volume loss - and therefore reduced blood pressure. He wrote in the patient’s notes that he thought this was the problem, “very pleased that we had identified what was going on, and what needed to be done for this patient.” When he told the Intensivist on duty, that doctor produced a paper headed ‘Capillary Leak Syndrome’, and explained that “Our trainee intern (a medical student) came up with this diagnosis last week, but because he was a med. student, we thought it couldn’t be true!”
“There are always interesting patients, all the time.” Currently they have a young woman with an adrenaline-secreting tumour in her abdomen, giving her very high blood pressure. “We are treating her, and she will have that surgically removed in a couple of weeks. . . . There’s always one or two patients who are of particular interest at any one time.”
Dr Manning’s closing comment, after mentioning his own participation in sport, was: “If anyone goes into medicine, make sure you have a balance in your life. It can just take over your life, try not to let that happen.”