Recently while visiting Melbourne, we dropped into a milk bar near our hotel to buy The Saturday Age. The other customer in the shop — an old-looking man with wild, grey hair and sun-coarsened features — was asking something of the woman behind the counter. I couldn't hear what the request was, but her answer to it was an emphatic 'No!'
The man thumped his hands on the sides of his Vinnie's suit pants and, screaming a string of expletives and racist slurs, he pushed past me and out of the shop. My 14-year-old daughter, shocked more by the intensity than the content of his outburst, had shuffled behind me as he was leaving. 'What was that about?' she asked, his ranting still audible through the front window.
My wife put her hand on my shoulder. 'Welcome home', she said to me with a smile. In the 1980s we had both trained at the inner-city hospital around the corner where this sort of interaction was a daily part of our life. Here was a survivor of a population that had been forced to move elsewhere by the invasion of middle class people like us.
My daughter, though, was having trouble disguising the fact that she could smell something awful. It was the pungent odour of the down-and-outer and its ability to linger after its source had moved on, that sent me back in time.
A large proportion of our patients were homeless men and women, mainly alcoholic. A few of them were 'characters' who were good fun to interact with. But most were very sad or very mad and essentially unreachable. They would turn up in the Casualty department throughout the day and night and I would sew up their lacerations, bandage sprained limbs, plaster broken ones and, on occasion, get them ready for neurosurgery to remove a clot from around the brain. I became proficient in the management of end-stage liver disease. It was not until I was rotated to another hospital that I learnt that alcohol-related problems were actually a little exotic in the mainstream medical world.
The homeless were usually brought to the hospital after they had been found in trouble by the police or by the ambulance. They rarely wanted the help we gave nor offered any thanks when it was provided. Their inability to look after themselves was often interpreted by the doctors and nurses as a conscious refusal to do so. The myth that 'personal responsibility' was a panacea ruled in some medical minds, and this belief legitimated their contempt for these patients.
Regardless of their sex, race or poison, one thing was always the same. The rank combination of urine, tobacco and the grime from cobblestones made them smell like a public urinal. So they were called 'dunnies'. If you asked a colleague what the preceding night shift had been like, the response might be, 'Not too bad, just an infarct and a couple of dunnies'.
I heard the term the moment I arrived as a student in 1980 and it seemed to be peculiar to our hospital. It was used by most of the resident staff but I never heard any of the consultants use it. In the beginning I thought that the word was harmless and I probably used it myself a few times.
One day I witnessed a registrar being spoken to by one of the nuns. 'I never want to hear you speak of any of our patients in that way', she said in a quiet voice. There was never any dissent when a nun spoke. A reprimand of this nature was uncommon but devastating. Such public admonitions pushed the word further underground but it did not disappear.
What drives those who have chosen a career that is supposed to be about caring to demean some of the recipients of that care? Every medical culture does it — The House of God, a 1970s novel about a Boston intern, popularised the term 'gomer', short for 'Get Out of My Emergency Room', which described a similar group of hapless and/or obnoxious patients.
But ours was worse: we were not just saying you smell like a toilet (because that was true) but that you are a toilet. The paradox was that our hospital really did reach out to the homeless and prided itself on its equity of access. Other hospitals would probably have been far less tolerant.
What we call people, regardless of our underlying motivation, can determine the way we treat them. Today most of the intolerance that I observe in medical staff is directed at patients who inject drugs: most hold quietly intolerant opinions, and the publicly proffered attitude of some senior colleagues would make you question their right to hold the title 'doctor'.
The injecting drug user is sometimes a 'junkie' or 'addict' but it is the behaviour of the staff that betrays their feelings. Some doctors refuse to take these patients' symptoms seriously, occasionally with the disastrous consequences of delayed and missed diagnoses.
Young doctors always buffer the real stresses of their work with humour that may not be appropriate for the uninitiated. But I think with this one we went too far, and even at this distance I am embarrassed by it. I made a decision never to call anyone a 'dunny' after I overheard the registrar's dressing down, and I made sure that no-one who worked under my supervision subsequently did either.
We should not be afraid of trying to change the culture of our workplace. I just needed someone to tell me that I could.
Frank Bowden is Professor of Medicine at the Australian National University Medical School in Canberra.