In Downton Abbey (ITV1), a good many scenettes – most are too brief to be scenes – are set up to climax with the wonderful Maggie Smith delivering a punch line. She has perfected the art of delivering these dénouementettes, which she does with a little shudder, as if a Tantric feather had tickled her G-spot. Last night she delivered a perfect corker: the decision lies with the chauffeur. In just six words, she encompassed a hundred years of medical and social history.
The dramatic tension at the heart of last night’s episode was the ancient clash between the GP and the specialist. It was as high concept as high stakes go: the life of a young mother was at stake. From the early moment a throwaway mention was made of swollen ankles, a pall-bearer of toxaemia, or pre-eclampsia, the obstetrician in Dr No knew it was going to end in tears. Fits would follow, and death was indisputably on the cards. The only question was how Julian Fellowes would deliver not the baby, but the eclampsia.
Meanwhile, the doctors battled it out. The smooth specialist called in from outside urged watchful waiting. He favoured the view that country lasses, even aristocratic ones, had thick ankles, and that was all there was to it. The local country GP, who knew his patient, was of the view that it was the smooth specialist who had something thick about him, and it wasn’t his ankles. Urgent delivery by Caesarean section – the only sure cure for eclampsia, though the risk remains for hours, even days after delivery – was imperative, even if it meant transfer to hospital. A lonely black in a sea of white ties, he backed up his argument with a urine test, a sluice-room vulgarity which discomforted the Earl, but which Maggie, with another of her little shudders, took in her stride. There isn’t much the Dowager Countess can’t take in her stride.
As the argument raged, she got to deliver the line. It was the upstart Irish father of the baby, the former chauffeur, who must decide; not the extended family nor the doctors. The mother was incapable – the confusion of severe pre-eclampsia – and the foetus had not a voice, so the father it must be, even if he was but a chauffeur. That we can forgive the Dowager Countess for, because in every other respect she was decades ahead of her time. And so it was that the chauffeur sided with the arrogant, misguided specialist, and Sybil’s fate was sealed. She did deliver the baby, a healthy girl, but eclampsia struck after birth. She fitted, went Wedgwood blue, and left the delivery room feet first. There was not a dry eye in Downton, let alone living rooms across the land.
Now, the reason Dr No has pegged this post on Downton is because it shows, in this episode, what it is that lies at the heart of good medicine: knowing your patient. The local GP may have been shamefully bullied and over-ridden by the specialist – and there is another lesson to be learnt there – but the GP knew the diagnosis because he knew his patient. Her knew Sybil from the top of her normally cool head to her usually slim ankles, and so made the right diagnosis. Today’s young GP trainees would do well to watch repeat loops of the episode, because in 48 minutes of Downton they will learn more about real medicine – the tension between specialist and GP, the doctor must advise but the patient decide, and most of all, the importance of knowing your patient – than they will ever learn from that extra dud year of training soon to be foisted on them by the Royal College of Caring and Sharing.