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Film Review: Patient

29 Sep, 16 | by cquigley

patient_still_looking_worried_in_hallway-1

 

The ten rules of doctors’ engagement

 

Review of Patient, Colombia, 2015, directed by Jorge Caballero

Screening at the London Film Festival, 15 and 16th October 2016

https://whatson.bfi.org.uk/lff/Online/seatSelect.asp

https://whatson.bfi.org.uk/lff/Online/mapSelect.asp

 

Reviewed by Dr Khalid Ali, Screening Room Editor

 

The Oxford Dictionary defines the word ‘patient’ as ‘a person receiving or registered to receive medical treatment’. Jorge Caballero uses ‘patient’ as the title for his documentary film, but we never get the see the patient, Leidy, a 23-year old girl who is bed-bound with an aggressive form of neuro-ectodermal tumour. The focus of the narrative is Nubia, Leidy’s long-suffering and ‘patient’ mother. Nubia is constantly with her daughter, pushing her hospital bed around to chemotherapy sessions, and for never-ending x-rays. When the doctors declare that the cancer is in its most-aggressive and terminal stage, Nubia decides to take her daughter home. However, first she needs an adequate supply of pain-relief medication. Securing these crucial medicines for Leidy’s comfort and dignity is a never ending quest between several hospital departments for official approval. Finding an ambulance to take them home is another harrowing exercise in endless bureaucracy. Nubia’s exhausting daily routine is only interrupted by brief moments of following ‘Colombia’s top model’ contest on TV.

Watching Patient reminded me of this statement from the Hippocrates oath: ‘I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug’.

Here are the ten lessons that doctors can learn from ‘Patient’:

*Don’t be afraid to say ‘I don’t know’, if you don’t know, don’t waffle: In one scene a junior doctor tries to comfort Nubia by asking her to keep ‘calm, be positive and tranquil’ when she was actually asking for an honest opinion of her daughter’s prognosis.

*Avoid jargon: in another scene, doctors explaining a possible tracheostomy tube for Leidy is a master-class in communicating the need for a complicated procedure with its associated risks and benefits- sensitively handled, ensuring understanding and offering the chance for questions and comments.

*Show empathy towards patients and their families: in several exchanges between Nubia and doctors caring for her daughter, it was clearly obvious that she was desperately seeking a professional to hold her hand in empathy.

*Reassure patients and families when dealing with intractable pain, and encourage them to ask if pain is not controlled: Nubia was constantly blaming herself for not getting the dose of pain relief right. She never questioned the hospital doctors’ prescribing competency.

*Plan ahead and get medications ready for a timely discharge: Booking an ambulance, getting the insurance paper work ready, and collecting her daughter’s medicines on the discharge day was a ‘mission impossible’ for Nubia.

*Respect patients’ confidentiality: In a sensitive approach to Leidy’s agony as a young girl at the end of her life, the film director never shows her face in a powerful statement of maintaining her dignity, and upholding her capacity in choosing not to be filmed.

*Care for the carer: after grilling journeys between various hospital departments, and home trips to get Leidy what she needs, it was apparent that Nubia wanted someone to ask her how she felt, and perhaps suggest some respite.

*Offer spiritual support: no mention was made of Nubia’s spiritual beliefs or if she practised any religion in the film. It might have been something that she was afraid to ask for! So as a doctor, do not forget to ask.

*Encourage patients and their families to share their hospital experience with each other: in a brief encounter with a fellow mother of another girl in hospital, Nubia gets to exchange a few tips on how to handle their ill daughters ‘crises’. Through this ‘solidarity and companionship’ both ‘patient mothers’ experienced a transient sense of support.

*Life can be short, so value every moment.

 

 

Address for correspondence

Dr Khalid Ali: Khalid.ali@bsuh.nhs.uk

Book Review: Dad’s Not All There Anymore

26 Sep, 16 | by cquigley

 

This is the first of a series of comic book reviews on the theme of Dementia. Reviews of Sarah Leavitt’s Tangles and Dana Walrath’s Aliceheimer’s to follow.

 

Demetris Cover

 

Dad’s Not All There Anymore by Alex Demetris

 

Reviewed by Harriet Earle

 

As an academic, I have a love-hate relationship with Wikipedia. I tell my students to steer well clear and never to rely on it for anything but the most cursory glances at a subject. However, I will admit that I use it regularly (and, in the website’s defence, the references can often be very helpful). There is absolutely a place in academia – and in life – for Wikipedia’s accessible and easy synopses. It is likely that, were I to require information on Lewy Body Dementia (LBD), I would soon be typing it into my phone’s app. However, one central thing that is missing from Wikipedia is heart. An encyclopaedia is not meant to be an emotional and emotive document; it’s aim is to inform, not to evoke emotion. However, when one is talking about many topics, such as LBD, the basic definition (or even an exhaustive medical definition) does not give any space to the consideration of the experience of the condition.

This is where Alex Demetris’ comic Dad’s Not All There Anymore comes in. Demetris illustrates his father’s diagnosis and eventual move to a nursing home. Demetris’ book is devastating and heart-warming. He tells the story through the figure of John. When the narrative opens, we are visiting John’s father, Pete, in a nursing home. John speaks gently to two other elderly residents, one of whom is supine on the floor, before meeting his mother, Sue, in his father’s room. The chronology of Pete’s illness is told in flashback; we follow him from diagnosis with Parkinson’s in 2003, to the diagnosis of Lewy Body Dementia in 2007 and the progression of the illness until John barely recognises his father. The personal story is interspersed with carefully worded explanations of the condition, its genesis and development that are pitched perfectly for readers who are not medics. This is the true success of this comic – that Demetris is able to create a work in which his father’s unique story and the more generic definitions of LBD sit in conversation with each other. We are in no doubt that this is a personal story and that it is the individual nuanced experience of the disease that is the focus, while the medical information exists within the text as an informative touchstone for the non-medic reader.

Demetris’ artwork is both expressive and simple. Plain line drawings with very little excess details are highlighted by shades of yellow-green. In places, there is a flash of red. When Pete starts to hallucinate a small red-haired child, she lurks as a faded red and creepily expressionless figure; she is almost a ghost. In another instance, Pete asks John what he sees in the corner. John sees a rack of coats; Pete sees the bright, terrifying face of a clown, to the horror of the clown-phobic John. In curious contrast to the muted and gentle colouration, the panels themselves are crowded. Each page contains at least 6 closely-packed panels, each one filled with a bustling image, topped with a caption or bubble or both. There is a lot to take in – both image and text – and at times the effect can be overwhelming. Where to look? What to read first? I would not wish to suggest that that chaos engendered by the reading experience can come close to mimicking the full horror and disorientation of LBD but it may go some way to mimicking the mental upheaval of supporting a family member.

All comics artists have a style and in that style is a peculiar ‘something’ that stands out. For Demetris, it is his exquisite use of eyebrows to create expression. In my own research, I have written about the importance of the eye as a frame to govern the emotion of the face within the panel. Demetris’ characters have no eyes, only small representative dots, and so it is for the eyebrows to do the talking. It is impossible to overstate how expressive Demetris’ characters are, a feat that is particularly impressive, given the limited use of detail in their faces. In the visually congested panels, the clearly rendered eyebrows on each face guide the narrative and emphasise the humanity of the characters, in moments of both comedy and tragedy.

Ask most people to name something that terrifies them and they are likely to rank dementia high on that list. I imagine that watching a loved one battle with dementia is equally terrifying. In the carefully rendered faces of John and Sue, there is immeasurable warmth. Indeed, one of the most striking features of the plot of this comic is the seemingly unwavering devotion of both characters to Pete and their tremendous patience with him as the disease progresses. It is one thing to say of a sick family member “he doesn’t mean to be trying, he’s not well – I will not hold it against him” and quite another to live these words and embody them. Demetris is not telling just any story of LBD, he’s telling his father’s story. The personal nuances of the story are the central focus of the narrative and the most compelling part of it. Pete was a teacher and regularly admonished his son for using the word ‘innit’ (“Don’t say ‘innit’ – it’s bad English”). At the book’s close, there is a final glimpse of the old Pete and his grammar policing ways (“… shouldn’t say ‘innit’… bad English…”). LBD may have him on his knees but he is still there and it is to this that his family cling. This is the heart; this is what moves this text beyond the crisp, cold definitions offered by Wikipedia and other encyclopaediæ. Instead of receiving the bare facts, the reader receives an insight into the day-to-day experience of the disease and the ravages it brings to bear on the individual and those around them. Demetris has etched out a fine line between text book and autobiography and is walking it with skill, panache and immense heart.

 

Dad’s Not All There Anymore by Alex Demetris is available from Singing Dragon Publishers.

ISBN: 978-1-84905-709-7

Price: £7.99

 

Related Reading

David M R Orr, Yugin Teo. Carers’ responses to shifting identity in dementia in Iris and Away From Her: cultivating stability or embracing change? Med Humanities 2015;41:2 8185

Martina Zimmermann. Deliver us from evil: carer burden in Alzheimer’s disease. Med Humanities 2010;36:2 101107

Global Humanities – Finding New Narratives

19 Sep, 16 | by cquigley

 

Conflict, Culture, and the Clinic: Finding new narratives

Ayesha Ahmad

 

In a recent publication “Syria Speaks”, the book volume is a collection of various forms of narrative that have been born in conflict. In reflection, there is a line that says: “War ignites people’s anger, and acts against culture, which is the work of the mind and the imagination”.

I find this interesting because culture becomes a force, a current of an ocean that is our imagination—our creativity, whereas war personifies all ways of life ending—killing, being killed, dying, and seeing others die.

Conflict is not culture. Rather, conflict unearths the skeleton of our human condition at the same time as burying the flesh from the bodies that are returned to the ground.

The ground, or land, is the bedrock of a conflict. The soil is separated and territories are disputed. The fragmentation of the land is a replica of the falling down of humanity. Pieces of the land are fenced away, boundaries that keep people apart from their footsteps.

I recall a passage in a story of four seasons in an Afghan village, recounting the lives of women weaving carpets; their hands moving in ways their grandmothers patterned the stories of their lives into colors and shapes.

The book, The World is a Carpet by Anna Badkhen, features a character called Amanullah. I was captured by the description of Amanullah walking “the trail by heart, steering from a memory that wasn’t even his own but had double-helixed down the bloodstream of generations of men who had travelled this footpath for millennia. A memory that was the very essence of peregrination, a flawless distillation of our ancestral restlessness”.

Our lives mirror our memories, and we carry our cultures; sometimes as treasures and sometimes as burdens.

I wonder about medicine. I wonder about a horizon where those walking from ancient paths like Amanullah entered new landscapes. I wonder about the doctor who encounters the Amanullah’s reaching Europe as refugees; what is the body when the body is without land?

If culture is our embodiment of the soil of our cradle, then medicine must confront culture in the clinical setting, as a form of sight, of hearing, of tasting, of feeling and of expression.

Our “travelling cultures” (Ahmad, 2014) must not be forgotten. In the examination of the toll of such journeys, medicine is challenged with new boundaries of healing and of humanity.

The question that emerges and I leave open for thought is “can doctors find a new narrative for culture in the clinic that inherently holds hope for the suffering?”

 

Reference

Ahmad, A. (2014), Do Motives Matter in Male Circumcision? ‘Conscientious Objection’ Against the Circumcision of a Muslim Child with a Blood Disorder. Bioethics, 28: 67–75.

Reclaiming Reflection: Creative Writing and the Medical Humanities (3)

16 Sep, 16 | by cquigley

 

 

Reminiscence Bumps: self-mythology and the landscapes of the mind

by Eleanor Holmes

 

When I think about the landscapes of the mind, I recall the undulations of the brain’s surface. The ridges and valleys of cortex, the gyri and sulci I had learnt about in my neuroanatomy classes aged nineteen. Those white plastic tubs we eased open to reveal two, pale grey hemispheres floating in straw-coloured formaldehyde. That clinical but distinctly organic smell of burnt rubber, astringency and wax. How we sliced sections of brain with something that resembled the knife my father used on home-cured ham. How surprisingly soft it was to cut.

Prior to starting my Spring School creative writing week at Newcastle University in 2014, I had read Pieces of Light: The New Science of Memory by Charles Fernyhough. It has been an invaluable source of information on the latest scientific research on memory, particularly autobiographical memory, but it has also been hugely inspirational as a piece of science writing (or creative non-fiction). Two things particularly stood out to me when reading the book and in researching this subject. Firstly, the notion that memory is random and secondly, that it is ultimately self-serving. As Charles Fernyhough states and the American writer and physicist Austin O’Malley wrote:

“Memory is a crazy woman that hoards coloured rags and throws away food.”

The randomness of memory is something that has often struck me. Why do we remember odd, apparently insignificant facts and not the things that would seem more important when looking back on our lives? Why can I recall the sandwich filling (garlic sausage) my brother threw out of the window that blocked the guttering, aged thirteen, but cannot remember the name of the actor who lodged with us? How can I remember the cigarette brand and packaging my grandmother smoked (Benson and Hedges, Silver) and a conversation we had about a TV programme aged fourteen but cannot remember any of the details of her funeral?

 Yet it is the small details, those seemingly random colourful rags that stick and then float to the surface when we recall the past, especially it seems when writing about it. It is particularly that rich period for memory from our teens to our twenties, the reminiscence bump that Charles Fernyhough writes about in Pieces of Light, that keeps emerging in my writing, whether I want it to or not.

“A British study showed that when autobiographical memories were cued verbally, there was a predictable peak between the ages of eleven and twenty-five: the well replicated phenomenon known as the reminiscence bump.”

The majority of the poems I wrote in 2014 for the Spring School fell into this verbally cued reminiscence bump. On the first day of our course, the poet Bill Herbert asked us to think about “where am I from?”, followed by “where do I identify as home?” This led to an exploration of self and belonging that I initially found hard to write about. I was born in Bristol, we moved to the Midlands when I was seven and there I stayed until I left for Nottingham University.

I disliked living in land-locked Warwickshire and didn’t manage to change this land-bound situation when I moved to Nottingham for university, but at least I had moved north. I have always been moving north, by increments, as well as edging closer to the sea. I had wanted to go to medical school in Newcastle but didn’t get an interview. I wonder whether it is really a coincidence of fate that led me to the North East (Durham initially and then Newcastle) or something that needed to happen; a kind of embodied genetic pull to this landscape next to the sea. Tynemouth is where I live now, positioned on the mouth of the Tyne and next to the North Sea with its wild surf and beaches, stretching up the Northumberland coast to Scotland like a golden thread. This is the place I am now most likely to call home.

What emerged from Bill Herbert’s class was a need to write about my birth, my mother and our at times difficult relationship. It was a theme that was to flow through all my submitted poems, along with water as the element that I most identify with. Bill also encouraged us to think of body as place, by reading an extract from Paterson by William Carlos Williams, a theme that resonated with me and the obsession I have with writing about the human body and my memories of anatomy and dissection from medical school.

It is now clear to me (after six years of pursuing a writing life alongside medicine) that when I write I don’t always decide in advance on form, I just like to write. It is later that I make a decision as to whether I am writing poetry, prose or script, when looking back over the words. Fiona Evans took our scriptwriting class mid-week and I was encouraged when she advised us not to be tied to form or structure. Her session also introduced me to Marina Carr as a playwright, specifically her play By The Bog Of Cats. As we read sections of this script it felt to me to be very poetic and suddenly the idea of scriptwriting seemed less daunting.

Learning about performance and the concept of the clown with ‘Miscreations Theatre’, and the history behind the art form with Helen Limon as facilitator, also influenced my poems, particularly the idea of embracing the ridiculous. The importance of being able to laugh at yourself I hope comes through in my writing. Black humour, said to be a medical trait but more often than not a coping strategy for the difficulties encounters of healthcare work, is something I often explore when writing about medicine and health. Too easily my writing can stray towards the subject of death; my father jokes that it is my favourite topic. It is perhaps an occupational hazard but I hope to strike a balance between being respectful of serious subjects whilst seeking out the humour inherent in most human interactions.

In William Fiennes’s class we were asked to draw a map from memory. I ended up drawing a detailed plan of my childhood home where we lived from the age of seven to sixteen, and wrote about the memories attached to this house. Here it seemed was an endlessly rich seam of childhood and teenage memories in terms of a reminiscence bump that still feels very vivid to me. I liked the idea of writing about my territory being invaded and many stories bubbled up from this exercise. I hoped it would link several themes together by highlighting an aspect of my growing up and the emergence of identity. This aspect of identity as an internalised life-story is another recurring theme in my writing, one that is so clearly linked to reminiscence bumps and the reason psychologists believe this age looms so large in people’s memories.

I am aware that much of what I’ve learned in creative writing workshops is that these small details – proper nouns, the use of all five of the senses when we write – that help to bring our writing alive. This must be linked to the way we remember. When we write we are creating a world (the world) for the reader, just as we do for ourselves when we remember the past. Memories are not stored like files in a cabinet, they are created anew each time we recall the past. We narrate our lives as serves us best at the time of recollection.

Childhood memories particularly are often recalled through collaborative acts of remembering, like a collage. I know that in a number of the poems I have written some details I’ve had to ask my mother about, as I couldn’t recall something exactly, or the name of a place or person. My mother, father and brother have helped me fill in the gaps where needed, but it is also noticeable that they do not remember everything as I do. Charles Fernyhough writes:

“The idea that the past is a story that we tell ourselves, whose vividness can be no guarantee of its authenticity, highlights our reliance on language for social acts of remembering. If our autobiographical memory system serves to create a coherent narrative of our own past, it is a system that can frequently fool us into believing stories that are not true, as evidenced by the fact that many of us ‘remember’ events that we no longer believe actually happened.”

This was the concept that I was fascinated to read about in Judith Schalansky’s beautifully realised Atlas of Remote Islands: Fifty Islands I have not visited and never will. Christy Ducker recommended this book (it’s really very beautiful, brilliant and unique) and the preface particularly intrigued me:

“The absurdity of reality is lost on the large land masses, but here on the islands, it is writ large. An island offers a stage: everything that happens on it is practically forced to turn into a story, into a chamber piece in the middle of nowhere, into the stuff of literature. What is unique about these tales is that fact and fiction can no longer be separated: fact is fictionalised and fiction is turned into fact.”

I think everything I write tends to start out as an exploration of autobiographical memory that I then run with, to a greater or lesser degree. Christy Ducker invited us to think of a place that we were experts on, then asked us to put someone into that environment who had no knowledge of it. This was the inspiration for My Mother Visits the Dissection Room, a blend of factual information in terms of place (the dissection room I remember from medical school and that I have lately re-visited) and my knowledge of my maternal relationship that ended up as a poem about an imagined scenario that incorporated all of these elements.

 

My Mother Visits the Dissection Room

by Eliot North

 

She said she wanted to go there.

So I pulled some strings,

read her the rules.

“Sensible shoes?” she said.

“Yes Mother. Plus clothes

you don’t mind ruined.

Fixers, they don’t wash out.

The smell will get you,

but not of death. More chemicals

like wax and rubber.”

But my mother, being my mother

didn’t seem to mind.

Walked right up to the

plastic head,

stuck her hand inside.

“You won’t even know

I’m here,” she said.

Pulled on a dark-blue lab coat.

Watched closely

as I unzipped the body bag,

revealed cavities and cages.

Stood on tiptoes to peer inside,

scribbled in her notebook.

So I placed a stool

three feet away;

her territory and mine.

When the students filed in

they looked at her,

the older woman with colourful shoes.

Whilst I quizzed the students,

she daubed her paints.

At the end they crowded round her.

Admired her line and

brave use of colour

whilst I put the organs back.

As the students left

she called out to them.

“Call me Poppy!” she cried.

They waved from the door.

“Weren’t they interesting?

What a wonderful body,

all those nooks and crannies.”

I slung the heart in a plastic bag.

Looked at my watch

before herding her out.

Then as we went to the door

she turned round and said,

“Shall we say the same time next week?”

 

Published by Ink, Sweat and Tears on 30/08/2016 http://www.inksweatandtears.co.uk/pages/?p=11697

 

These two concepts, the unreliability of memory and the way in which we narrate our lives using a blend of fact and fiction to best suit ourselves at the time of telling, is endlessly fascinating to me. I’ve struggled at times to differentiate between what I think actually happened and what I have imagined when recalling the past. The poems I write are often a conscious blending of fact and fiction, something termed in memory research as imagination inflation (what a great term!) I don’t like to pin down my writing necessarily as creative non-fiction. I would prefer to think of my poems as fictionalised truths. In this my drive towards a cohesive narrative wins each time; I will bend the facts to meet the needs of the story I am writing. Who hasn’t done that after all?

 

Acknowledgments

This essay draws on the poetry, prose and script suggested by tutors Bill Herbert, Christy Ducker, Fiona Evans, Helen Limon and William Fiennes, as well as the following books, performances and readings:

Fernyhough, Charles, 2013, Pieces of Light: The New Science of Memory, London: Profile Books Ltd. (quoted passages p 3, p 20, p 54.)

Ishiguro, Kazuo, 1995, The Unconsoled, London: Faber and Faber Ltd.

Lively, Penelope, 2013, Ammonites and Leaping Fish: A Life in Time, London: Penguin Books Ltd. Extract read by the author at NCLA Reading: ‘Penelope Lively in conversation with William Fiennes,’ on 1/5/14.

Payne, Nick, 2014, Incognito, London: Faber and Faber Ltd. (Script) and Performance at Live Theatre, Newcastle, 30/4/1/4 followed by post-show discussion with the author, neuroscientists and clinicians working with memory disorders.

Schalansky, Judith, 2010, Atlas of Remote Islands: Fifty Islands I have not visited and never will, London: Penguin Books Ltd. (quoted passage pp. 19 – 20)

Henig, Robin Marantz, The Reminiscence Bump: People looking back on life remember their twenties best. Psychology Today, Posted October 24, 2012. Cited https://www.psychologytoday.com/blog/cusp/201210/the-reminiscence-bump 2/8/16

Reclaiming Reflection: Creative Writing and the Medical Humanities (2)

15 Sep, 16 | by cquigley

 

Creative Non-Fiction: imagination and the nature of truth

by Eleanor Holmes

 

A copy of Primo Levi’s The Periodic Table lay on my bookshelf for years, a gift from my father, one of his favourite texts. The fact that I’d not actually read it until my creative writing tutor at Newcastle University, the author William Fiennes, re-introduced me to the collection, specifically the final story Carbon, reveals how I had for most of my life considered non-fiction to be less worthy of my time than fiction.

Why had I drawn such a distinction?

I had read numerous books at medical school by Oliver Sacks, such as The Man Who Mistook His Wife for a Hat and more recently Hallucinations. These books, it turned out, definitely fell under the banner of creative non-fiction. On the one hand they could be considered factual science writing, but Oliver Sacks as an author seemed to be doing so much more than that. This realisation made me re-think what this genre was or indeed could be. Since taking William Fiennes’ module in 2013, my consumption of creative non-fiction has dramatically increased and shows no signs of abating.

Creative non-fiction, as I now understand it, is writing based in truth that uses literary techniques more commonly associated with poetry, prose and script. The attention to character, voice, style, shape, structure and form mark out this genre from journalism and reporting; the facts of a piece not necessarily being as important as the way in which it is written. For me, the words ‘not necessarily’ are crucial here.

The suggested reading list provided by William Fiennes surprised me in its breadth and scope: memoir, reportage, nature writing, science writing, portraits, travel writing, case studies and essays. Unwittingly, I had read more than I had expected but it had never occurred to me to ask, “What kind of book is this?”

In favouring fiction, particularly the novel, I’d often sought to escape reality and move away from my own experiences as a child, growing up, going to medical school and latterly working as a doctor. I soon noticed that in writing creative non-fiction, whether telling your own story or that of another person, the writer can leave themselves very exposed. There is something that appeals to readers when an author states ‘this happened’ – to them or to someone else. It creates a stamp of authenticity that can be quite interesting to unpick.

The criticism Jon Krakauer received after publishing Into Thin Air is a reminder of this. In telling his own story, he was also telling the story of those who had died on Everest. His book reads like a thriller, the tension created by the narrative pace is palpable, but the story was never going to be easy to write or to be without its controversies. The moral and ethical debate surrounding consent and sensitivity when writing creative non-fiction is very interesting to me, particularly as this is something I have wrestled with when I have wanted to write about my own work as a doctor, the truth of my own experiences.

Having researched the science behind memory, I now know that when we recall something, memories are created from scratch using different areas of our brain. In remembering, we create our own unique version of the truth, every single time, which begs the question “what is truth anyway?” The latest scientific research on memory, gleaned from my reading of Charles Fernyhough’s fascinating book Pieces of Light, sits quite neatly alongside the fact that creative non-fiction can often blur what has happened (fact) with things that have been imagined (fiction). This creative license and economy with the truth when telling our own stories is something we are all likely to be familiar with, writers or not. I cannot remember with perfect accuracy conversations I had at the age of ten, but I can use my imagination to fill in the gaps, thereby telling the story I want to tell.

This seemed a minefield to me when I started to write, so much so that I wrote under a pen name and still do. This name is no longer a secret, I have become more comfortable writing about my experiences as time has passed. It now acts as more of a separation of my writer and doctor roles. The professional duties I am bound by I take very seriously; those of anonymity, confidentiality and consent. But these same concerns paralysed me for many years in terms of writing about my life as a doctor and all that medicine has done to shape who I am. The subject of family I find far easier to explore than strangers, colleagues or indeed patient encounters; not that I do not also consider and respect those professional parameters when writing about my family, particularly consent, as my mother will attest to in my latest series of creative non-fiction blog posts entitled Consultations with my mother.

The two poems I’ve written and published about clinical encounters (He Blew Me A Kiss in the previous post and The Milkweed Monarchs here) are two examples of how you can blend medical science and clinical detail within a human narrative, writing from different points of view, using characterisation and voice alongside a narrative arc. Interestingly, I can’t seem to write poetry without some kind of narrative inherent in them, perhaps because I was a prose writer before I started to write poetry. It wasn’t possible to gain consent to write these poems from the persons that inspired them, so providing anonymity was very important when I considered publication; a very deliberate blurring of fact and fiction.

One writer from William Fiennes’ reading list particularly stood out for me, and that was Jo Ann Beard. We read her story Werner, and the dramatic tension she created and her poetic prose style mesmerised me. This was a piece of writing based in truth, but it was someone else’s story, that of a man called Werner who the author had read about and contacted. The way she got inside his head, however, and the use of flash backs was so effective at creating this man’s inner world as well as re-enacting the outer facts of his extraordinary escape from a burning building, that you felt you were experiencing what happened as if you were Werner himself.

What particularly struck me after reading this was “how did she achieve this?” I have since researched Jo Ann Beard and found her writing described as ‘dramatic re-enactments.’ I went on to source another essay called Undertaker, Please Drive Slow which was published in Tin House after The New Yorker declined to run it as creative non-fiction. She wrote this forward to the piece:

In December 1997, Cheri Tremble committed suicide with the assistance of Dr. Jack Kevorkian. What follows is a merging of fact with fiction: the external details of Cheri’s life and illness are as accurate as possible, gleaned from interviews with her friends and family, while the internal details – her thoughts, her memories, and what occurred after her loved ones saw her for the last time – are imagined.”

In Undertaker, Please Drive Slow she utilises flash backs to Cheri Tremble’s past and childhood, flickering memories that mark her decline from a healthy, working woman and mother through her diagnosis of breast cancer, the treatment she endures, then her terminal decline. The images she uses to convey the final circumstances of her death are free of cloying sentiment and all the more powerful for it.

This writing is however right on the edge, clearly controversial because of the subject matter and the question of ownership as well as truth, whatever we mean by this. It does however shed light on a subject that is so rarely spoken about, that of death and dying. Clearly we cannot ask the person who has died to tell us about their experience of dying, but in this extraordinary essay I feel Jo Ann Beard comes as close as possible to doing that. There is a kind of alchemy at work here, the way she pushes creative non-fiction as a genre to its very limits to explore an emotional truth that I believe would not have been possible if this had been written as fiction.

Primo Levi notes in Carbon his final essay of The Periodic Table:

The reader, at this point, will have realised for some time now that this is not a chemical treatise: my presumption does not reach so far… Nor is it an autobiography, save in the partial and symbolic limits in which every piece of writing is autobiographical, indeed every human work; but it is in some fashion a history.”

I have now finished reading The Periodic Table, a book that defies easy classification, something I now realise is a positive draw for me and that I seek to explore in my own writing. The blend of short stories, memoir and science writing, woven together by Primo Levi’s love of chemistry, his training and work in this field, his survival of Auschwitz and the horrors of the Holocaust, and his undoubted genius with words is such a moving and life-affirming whole.

BBC Radio 4 have just dramatised The Periodic Table for radio, the different chapters named after single elements from the periodic table broadcast in episodes, ranging from fifteen minutes to an hour. This provides a perfect entry point to Primo Levi’s work as well as a way in to explore this rich and endlessly rewarding genre of creative non-fiction. If you read or listen to no other essay of Primo Levi’s make it Carbon, the story of a single atom of carbon as it journeys from limestone crag to the author’s brain cell as he writes. As William Fiennes said to me it is perfection in writing, the perfect full stop.

BBC Radio 4 iPlayer: Primo Levi’s The Periodic Table, available now: www.bbc.co.uk/programmes/p040d1vz/members

 

The Milkweed Monarchs

by Eliot North

 

I was riding my favourite bike. The Chopper

with the red flag and the silver streamers on the handlebars.

Minding my own business, cruising down Beach Road

to school at Kaikoura Flat. Happened right outside the

Whale Watch Office. “Idiot tourists,” Dad said,

“never bloody look where they’re going.”

 

Don’t remember much after that. Just the pain

in my belly, the voming and that funny shaped

bruise that crept like a shadow across my skin.

“Handlebars mashed his Pancreas,” the guy said to Mum

after they airlifted me to Christchurch. Wish I could

remember the ride. They’d given me the needle by then.

 

Couldn’t understand a word when I came to; most of

the docs were from England. Got my own room

on the kids ward though, was pretty stoked at first.

Turns out nine weeks in one room can really turn you off

a place. Kept telling me I couldn’t eat and put a stupid tube

in my chest, for that pseudo-food to drip in overnight.

 

Would’ve gone mad if it weren’t for the Monarchs.

Mum and Dad bought them in from the farm,

loads of tiny ones on bunches of Milkweed. Boy were

they hungry, just ate and ate whilst I couldn’t. Got fatter

and fatter, the black and yellow stripes growing further

and further apart. They were more interested in them than me.

 

Didn’t mind though, those ugly critters. Gave most of them

names. Watched how they crawled around my room before

they tucked their tails under like upside-down question marks.

Mum said I was daft, but I knew the Monarchs would save me.

As soon as they slipped into those bright green overcoats

and changed for good, with their precious crowns of gold.

 

“Coincidence,” the docs said. I don’t reckon. My pancreas

would’ve been stuffed if it weren’t for them. When the cocoons

turned black and then transparent, I could see the orange

wings inside.  First one came out all small and wet with

a loud POP!  Like the noise my brother makes when

people kiss on TV. I knew it was my time too.

 

Just pressed the buzzer and the nurses came flying.

Pulled out the drips, blood spurting over the sheets

but I was free. Stretched my arms wide and stuffed a

Chocolate Fish in my mouth before they got near my room.

You should’ve heard the shouting but I didn’t care;

there weren’t no Pseudocyst in me no more.

 

Commended in the Hippocrates Poetry Prize NHS category 2014

http://hippocrates-poetry.org/hippocrates-prize/2014-hippocrates-prize-open/2014-hippocrates-commended.html

Published in the accompanying anthology

 

Acknowledgements

This essay draws on the suggested reading list provided by William Fiennes for his Creative Non-Fiction course at Newcastle University and the following books, periodicals and podcasts:

Beard, Jo Ann, 2002, Undertaker, Please Drive Slow, Tin House Magazine, Portland: McCormack Communications. Vol. 3, No. 4, pp 27 – 59.

Levi, Primo, 2000, The Periodic Table, Penguin Books, London. Translated from the Italian by Raymond Rosenthal.

Fernyhough, Charles, 2012, Pieces of Light: The New Science of Memory, London: Profile Books Ltd.

Cusk, Rachel, 2013, New Writing: Memoir, Newcastle: Mslexia Publications Ltd. pp 30 – 42.

Radiolab podcast: Season 3, Episode 4, 2007, Memory and Forgetting, New York: accessed 1/3/13 at www.radiolab.org.

N+1 podcast: Episode 3, 31st August 2011, Both Fish and Fowl – Jo Ann Beard, New York: accessed 16/3/13 at www.nplusonemag.com.

Reclaiming Reflection: Creative Writing and the Medical Humanities (1)

14 Sep, 16 | by cquigley

 

Poetry and Reflection: a powerful tool for learning

This post is part of a series over the next three days on the theme of Creative Writing and Medical Humanities by Dr Eleanor Holmes (pen name Eliot North).

 

 As a GP Tutor I’ve delivered seminars on the patient centred medicine (PCM) component of Newcastle University’s Medical Undergraduate (MBBS) course to 1st and 2nd year students, for the past three years. Professional reflective practice is taught and assessed across all five years of the curriculum.

The ability to reflect and learn from clinical encounters is central to medical education and continuing professional development. Delivered within a creative context, I believe written reflection can also be an important tool to foster wellbeing and resilience in healthcare students and professionals.

Working in an increasingly overstretched and under resourced system such as the NHS, in which clinician burnout and mental health problems are on the rise, the question of how we reflect on the difficult and complex nature of care is becoming ever more important to address.

Stating that the answer might be found outwith Medicine may seem heretical, but it is my belief that we need to look outwards to move forwards. The Arts and Humanities, like Health and Medicine, explore and reflect upon the human condition. What therefore can we learn from each other?

My last seminar with my first year group was entitled ‘Professional Reflective Practice 2.’ After a year of working together trust, an essential element of clinical reflection, had been built within the group. I used my own writing, a poem called He Blew Me a Kiss, as a launch point for discussion, which was published under my pen name Eliot North.

 

            He Blew Me a Kiss

 

She liked Frank, they connected

despite his expressionless face. Behind the wound-up limbs and tremor

a gentle man shone out from the mask.

 

When she visited they would share a cuppa,

chat about this and that. Do the ‘medication shuffle’;

a two-step dance they both knew well.

 

She’d heard about stem cell research.

How they’d taken swabs from patients’ skin. Growing stem cells

from skin cells in dishes, right there in the lab up the road.

 

These stem cells would then become brain cells.

Models of Parkinson’s just like Frank’s. For testing newer and better

medications and perhaps one day even a cure.

 

The last time she saw Frank it was snowing

but he insisted on accompanying her out. Standing by the gate like a sentinel

he’d wave her off that one last time.

 

Later she’d think of stem cells like kisses

blown on the winter air. The moment captured in her rear-view mirror;

A hand lifted slowly, toward a frozen face.

 

Published by EuroStemCell ‘Tales from Within: Imaginative Non-Fiction on Stem Cells,’ 2013. (Frank is a pseudonym)

http://www.eurostemcell.org/he-blew-me-kiss-eliot-north

 

I have found that reading a poem aloud, that I’ve written myself, is an extremely powerful learning tool. There are obvious medical elements I can draw out regarding Parkinson’s Disease and stem cell research, but more than that the poem makes an important statement about connectedness, communication, the complex and varied role of a doctor as well as the limitations of medical science. It speaks to students about the importance of getting to know patients and continuity of care; how embracing the humanity in an encounter can be both powerful and revelatory.

The moment captured in the poem will live with me until the day I die, reading it always chokes me up; I choose to show this emotion to my students. We as clinicians who teach, whether in seminars or on the wards and in clinics, are hugely powerful role models. By stating and showing that this encounter moved me I am by example saying, “It’s OK to show emotion.” This leads to discussions about professionalism, boundaries and clinician wellbeing linked to the evidence base that demonstrates better patient outcomes when doctors show that they are emotionally affected when breaking bad news.

I wrote this poem many years after the event, it was something that sat in my brain waiting to come out. I wish that I’d been able to share it with the man who inspired the poem but he died some years before I got it down on paper. It was a EuroStemCell competition, partnered with the Centre for Regenerative Medicine in Edinburgh that spurred me to write it.

The challenge to submit an ‘imaginative non-fiction’ poem that incorporated stem cell research brought this encounter immediately to mind, the link between stem cells and Parkinson’s a way to explore how I felt about this patient. Discussing the creative process and the fact that I write under a pen name and changed the patient’s name forms a nice link to the importance of anonymity, confidentiality and consent, as well as patient and doctor voice.

With my students I then facilitated a creative guided writing exercise on a memorable clinical encounter followed by small group work, drawing and writing Haiku. The seminar culminated in poster presentations delivered by the students to the group. The results were insightful, empathetic and moving; their use of metaphor and close observation giving authenticity to the explorations they had made of encounters with patients and carers struggling to cope with dementia, a potential diagnosis of cancer and the communication difficulties witnessed for a patient with learning disabilities, linking this to issues of capacity and consent.

As someone who uses creative outlets as a way of coping with the stresses of practicing medicine, it amazes me that the word ‘creative’ can strike fear in to the hearts of medical students and healthcare professionals alike. I believe that by embracing creativity and essentially our inner child, written reflection can be much more than a required component of assessment and appraisal. All humans have the capacity to be creative, no matter how much they protest to the contrary. The skill lies in being able to coax it out of them.

 

Acknowledgements

All of the work I’m currently doing in this area is in collaboration with Sue Spencer with whom I wrote the guided writing framework I used above with my students, influenced by reading the books and on-line resources below. We are delivering a ‘Reflection of Clinical Encounters’ workshop using creative writing methodologies in November 2016 for the Staff Development Programme, School of Medical Education, Newcastle University.

Writing Poems by Peter Sansom, Bloodaxe 1994

The Poetry Toolkit – The Poetry Trust 2010, available as a free PDF download http://www.thepoetrytrust.org/images/uploads/pdfs/Toolkit%20for%20Teachers.pdf

 

Related reading

S E Gull, R O’Flynn, J Y L Hunter. Creative writing workshops for medical education: learning from a pilot study with hospital staff. Med Humanities 2002;28:2 102104

Khaled KarkabiOrit Cohen Castel. Teaching reflective competence in medical education using paintings. Med Humanities 2011;37:1 5859

T J Collett, J C McLachlan. Evaluating a poetry workshop in medical education. Med Humanities 2006;32:1 5964

Film Review: X + Y

13 Sep, 16 | by cquigley

 

X+ Y- UK, 2014, directed by Morgan Matthews

Reviewed by Dr Khalid Ali, Screening Room Editor

 

Books, films and plays exploring the Autism Spectrum Disorder (ASD) have traditionally met with critical acclaim; ‘The Reason I Jump’ (https://en.wikipedia.org/wiki/The_Reason_I_Jump), ‘The Curious Incident of the Dog in the Night Time’ (https://en.wikipedia.org/wiki/The_Curious_Incident_of_the_Dog_in_the_Night-Time), and ‘Rain Man’, USA, 1988, directed by Barry Levinson (https://en.wikipedia.org/wiki/Rain_Man) being notable examples.

‘X +Y’ is a film in the league of cinematic outings inspired by a true story exploring ASD. Nathan Ellis (Asa Butterfield) is a young teenager who was diagnosed as a child with ASD. Following his father’s untimely death in a car accident, he rejects his mother Julie’s (Sally Hawkins) attempts to bond emotionally. Nathan’s Maths teacher in school, Mr Humphreys (Rafe Spall) recognises Nathan’s gift for numbers, and offers to mentor him in the preparations to be a member of the UK team for the International Mathematical Olympiad (IMO). After being selected to represent the UK, a trip to Taiwan forces Nathan to deal with bullying, peer pressure, as well as the woes of first love with a fellow Maths prodigy Zhang Mei (Jo Yang). Nathan starts to reconsider his priorities in life. Is bonding with numbers and calculus theories more rewarding than bonding with humans? Can he transform his teacher’s bleak views on life? Can he reconnect with his mother?

The film is based on the life of Daniel Lightwing who represented the UK in the IMO in Slovenia in 2006, and whose story was first seen in the documentary film ‘Beautiful Young Minds’ (https://en.wikipedia.org/wiki/Beautiful_Young_Minds). Being a fiction film, ‘X+Y’ deviates from Daniel Lightwing’s life story in several key areas: the IMO was held in Slovenia, and not in Cambridge, Daniel’s father did not die in a car accident, and his Maths teacher was a woman, and not a man as seen in ‘X + Y’.

The film depicts several common features of ASD (social deficits, communication difficulties, and stereotyped behaviour). As the story unfolds, the viewer is led to empathise with Nathan’s mother in her frustration to understand what is going through his head; his refusal to hold her hand at his father’s funeral, his outburst after getting a Chinese take-away with an even number of prawn balls, and his harsh remarks that she is not ‘clever enough’. Obviously one film cannot cover all issues relating to the complexity of a family’s reactions to raising a child with ASD. However, ‘X + Y’ does go a long way towards shedding a light on analysing the feelings of guilt, as well as on the self-doubt that some parents experience. Such themes were similarly dissected in more detail in the UK TV series ‘The A word’ (https://en.wikipedia.org/wiki/The_A_Word)

Through imaginative use of light and sound, the film convincingly demonstrates the phenomenon of synaesthesia, where stimulation of one sensory pathway leads to an automatic and involuntary experience in a second sensory or cognitive pathway: Nathan’s mathematical puzzles are thus transformed in his brain into shapes of bright colours. His outstanding mathematical skills make him a ‘savant’; however this gift does not bring him happiness or contentment. Nathan’s isolation is felt even amongst his peers at the Maths camp in Taiwan. Having a gift for numbers can be a curse as well as a blessing – being totally absorbed in the world of numbers alienates the ‘synaesthetist’ child from his school peers – he/she is perceived as the school nerd/geek who most kids avoid and ridicule.

With its heart in the right place, the messages that ‘X+Y’ conveys – an understanding of people who are different, promoting tolerance and empathy – are welcome. However, it risks perpetuating the notion that children with ASD have to be exceptionally talented to be accepted by society, what Nathan’s companion in the Squad team describes as ‘If you (someone with ASD) have the gift, you will be called ‘gifted but weird’, but if you don’t have a gift, you will be labelled as ‘weird’ only’.

The viewer potentially struggles with too many plots – Mr Humphrey’s problems with MS, drug addiction, and social isolation warrants an entire film alone. Nathan’s story has a happy ending, and provides a crowd-pleasing moment, but it underestimates the harsh realities lived by children and families affected by ASD. Still, it is a welcome piece of film making that is both moving and brave in its depiction of what it feels like to be diagnosed with ASD.

Address for correspondence: khalid.ali@bsuh.nhs.uk

 

 

 

Poetry Book Review – Cancer Poetry

10 Sep, 16 | by cquigley

 

Ian Twiddy, Cancer Poetry. Palgrave Macmillan, 2015

Reviewed by Sue Spencer

 

Cancer remains one of the most feared of diseases. It evokes dread in the general public and stimulates startling headlines about its insidious and destructive nature. Even as knowledge increases and cancer detection rates improve, this remains the case, despite the fact that cancer is now more treatable and curable than ever. Given this shift in experience of cancer, I had hoped that Cancer Poetry might provide an insight into how poets and poetry have helped humankind navigate this tricky terrain – a big ask I realise, but I do believe that poetry has the potential to achieve this.

I looked forward to reviewing this book. As a nurse, an educator and a writer, I am committed to improving patient experience of health care. I believe that creative approaches can be very powerful in terms of bridging the gap between patients and professionals in the clinical encounter. I am committed to Julia Darling’s project of promoting poetry within this arena. Julia’s introduction to The Poetry Cure, where she shared her own experiences of writing poetry whilst being treated for breast cancer herself, exhorts the benefits of poetry in health and illness:

 “I believe that poetry can help you make you better. Poetry is essential, not a frill or a nicety” (1)

Knowing Julia, I also know that she did not see poetry as an elitist enterprise. She created spaces where wonderful poetry could be responded to in an accessible and enabling way. However, the poetry world does have a problem with being perceived as elitist, with discussions around poetry sometimes viewed as alienating and “other worldly”. Many people I encounter do not often see the relevance of poetry to clinical practice until they actually experience its alchemy and find out for themselves how metaphor, metonym, rhythm, patterns of speech and language itself can shed light on the everyday, particularly in the context of health care practice.

I have to confess to finding Cancer Poetry a difficult read, and found myself skipping significant chunks where it did not engage me. I found the author’s sweeping generalisations and unsubstantiated comments particularly irritating. There are no references to psychological and sociological literature that might illuminate what might be “going on” in a poet’s work.

My first question relates to the inspiration behind this book. Why it was written? Was there an intellectual or emotional impetus to analyse this subject? My personal feeling is that Cancer Poetry reads as an intellectual exploration, in contrast to work such as that of Julia Darling, which, by encouraging us to confront raw emotions and to deal with contested realities, establishes the potential for poetry to help patients and professionals during demanding treatment regimes. Cancer Poetry is a dense book, with an undoubtedly rich content, but I struggled to grasp its potential within the context of improving the experiences of people living with cancer and its treatment.

The opening chapter attempts to chart the terrain, but seems to end up being more of a celebration of Paul Muldoon and his work. There appears to be an ambivalence about whether cancer should be written about and a reluctance to state a position as to whether it is a worthy subject and whether “good” poetry results. There is also a limited review of the foray of other disciplines into this subject – for example, the role of linguistic scholars and the pervasiveness of the war metaphors used to present people’s experiences of living with cancer. I disagree with the author when he states that a similar language is not used in the discourse around other conditions – we hear of ‘wars’ on obesity, people ‘battling’ neurological degeneration etc.

The opening chapter discusses high profile survivors and battlers of cancer, for example Jane Tomlinson and Lance Armstrong, but all of this misses the point that these “celebrity” patients are not typical or representative of most people’s experiences.

The chapters that follow are categorised around specific themes and this is where I found more traction and some engagement in relation to the discussion. However, I would have liked to have known why the author chose the poets that he did. After all, there is a huge body of poetry written about cancer experiences from a range of perspectives and the analysis in this book seems partial and limited. There is also little discussion of the poems in the context of the poets’ other works. It can be very narrow to discuss poems solely on the subject they explore rather than within the landscape of a poet’s other work or within a historical or cultural context. People’s experiences of cancer are often shaped by their health care encounters, cancer treatments and their side effects, relationships with health care professionals, and ongoing uncertainties around choice and prognosis. All of this must inform poetry written on this subject, yet I found myself not being able to grasp the arguments presented in Cancer Poetry.

This book represents all that I find difficult and challenging in the world of medical humanities. For me, Cancer Poetry is not an example of a melding of knowledge and theory. It is a book of literary criticism on poems written about cancer. I may be wrong, but if we want to engage health care practitioners in the merits of the humanities, to enhance their practice we need to focus less on intellectual silos and more on making connections, sharing insights, creating synergy and stimulating new thinking. I wish this book had done that.

 

Reference

  1. The Poetry Cure edited by Julia darling and Cynthia Fuller 2005 BloodAxe Books http://www.bloodaxebooks.com/

Poetry Book Review: The Wound Dresser

7 Sep, 16 | by cquigley

Two poetry book reviews will be featured this week. The second review will appear on Friday.

 

WoundDresser

 

Jack Coulehan, The Wound Dresser (Albuquerque: JB Stillwater, 2016)

Finalist for the 2016 Dorset Poetry Prize, selected by Robert Pinsky (Poet Laureate of the United States from 1997 to 2000).

Reviewed by Barbara Salas

 

The Wound Dresser by Jack Coulehan is a collection of 77 poems that explore the reality of being a physician, reflect on health and illness, and delve into the experience of suffering from different angles. In the following lines I will share how Coulehan’s poetry has made me reflect on diverse aspects of life, disease and on the art of medicine.

The book is the author’s sixth collection of poems, and its title alludes to a composition by Walt Whitman (whose photo appears on the book’s cover): verses that speak about the care of wounded soldiers during the Civil War, and to which Coulehan dedicates his very first piece of the collection. This theme of looking after the sick is central to the author’s poetry.

The order of the poems, though not clearly stated, seems to reveal the passage of time: from the “The Secret of the Care”, which opens the first section exploring the feelings of a junior doctor, to the very last poem of the series, “Retrospective”, which is a reflection on forty years of medical practice. This subtle timeline is structured into four parts, each one orbiting around common themes.

The first section comprises poems that generally reflect on the doctor-patient relationship. A recurrent element of these compositions is the idea of the physician as the one who witnesses the inner secrets of the patient. In “Take Off Your Clothes” we are invited to think about the physical examination: the patient exposed and vulnerable, and the doctor as the one with access to the “narrative in [the patient’s] flesh” (p. 23). Physician and patient are “intimate companions” in a journey through the intricacies of the body, in which we appreciate compassion and loving care from the doctor, but also patent fear from the patient: a topic often conveyed in Coulehan’s poetry (e.g. “The Rule of Thirds”, pp. 26-7).

However, the relationship established between doctor and patient, though close, appears to be at the same time “detached”, perhaps because the access to those secrets does not necessary grant intimacy. In fact, it sometimes seems to signify the opposite, something like a “cold distance”. The four poems “A Lesson in Diagnosis” (pp.5-8) convey to me this tension between “union” and “separation”. The closeness is transmitted through the acknowledgement of the patient’s vulnerability during the clinical exam (“During the discussion/ she keeps trying without success/ to cover her nakedness with a sheet.” p. 7), but the distance is present in the detachment that the doctors demonstrate both in their use of language as well as in their actions (“He drags us to another case —/ this one, a supraclavicular mass./ No one stoops to pick up her glasses.” p. 6). It is clear that while the patient is embedded in pain and anguish, the doctor sees and identifies the problem from afar, without being part of it or experiencing it.

Some poems reflect on the process of learning to practice medicine, and the feelings and thoughts that the clinical encounter trigger in the physician. The need to pretend to be competent (“I palpated/ their abdomens, balloted their livers,/ and listened to respiratory crackles,/ while disguising the depth of my doubt/ with a kindly, but serious look.” p. 3), or the difficulty in interacting with some patients (“I was surprised to find/ how much I disliked some of the patients” p. 3) is present in “The Secret of the Care”, the first poem of the collection. This made me ponder on the physician as the one who has two identities that sometimes stand in tension: on the one hand, the “professional” side that actively cares for the patient; and on the other, his inner world full of thoughts, worries and prejudices that are often hidden in the consultation yet present in his mind.

Finally, the contrast between the patient’s inner life and the painful reality of being ill captured my attention in this section. “The Silk Robe” (pp. 16-7), offers a glimpse of the patient’s life beyond the clinical setting by underlying details like her “blue silk robe”, her “scent” or her “delicate gold chain”. What those details evoke sharply contrast with the reality of her medical condition: the “cultures”, the “catheter”, and the “bed rest” reminds us that she is sick. While reading this poem I thought about the clinical encounter, during which sometimes doctors interact with patients as if their whole being were only their disease. Those doctors sadly forget that the patient is first and foremost an individual; a human being with an inner life that has to be acknowledged and respected. These two dimensions (the person as patient and as individual) are beautifully captured in Coulehan’s literary work.

The second section conveys, through reflections on historical figures or events and mythical accounts, how medicine has changed through time. It also reflects on how human elements like prejudices, fears or beliefs can shape the interaction between doctors and patients, both in the past and today. “To the Heart of Lazar Riverius, Galenist Physician” (p. 40) presents the contrast between the current medical practice (one that operates without “faith” and in a somewhat “mechanical” fashion) and the medicine of the past, which used to embrace the spiritual dimension of the person more openly (“Today the surgeons shut you down,/ open, patch you, put in plastic —/ and not a single Sign of the Cross!”).

In “McGonigle’s Foot” (pp. 42-3) we see how a century and a half ago (1862) prejudices on identity and nationality shaped the medical practice: since the patient is “a foreigner, a drunk, and loud” [emphasis original] there is no need to anesthetize him. (In the notes [pp. 99ff.] we learn that the poem was based on the idea that surgeons back then only gave opiates and alcohol “selectively”). Although we could be tempted to think that this speaks of something that only occurred in the past, the poem reminded me of recent published research in the US, which proves that today black people are less likely to be prescribed opiates for pain management than their white counterparts.1

The third section is a compilation of reflections on the passage of time, on life, and on death. Those moments occur around the world, in places like Alaska, Alexandria, Kosovo, or Cambodia. There are poems on the horrors of war (“War Remnants Museum, Ho Chi Minh City” p. 56), on the passage of time (“Deliver Us From Evil”, pp. 64-5), and on the contrast between life and death: in “Cesium 137” (p. 68) we are presented with a scene in Brazil where the same substance that uncovers the “loveliness” of the children (“their loveliness aglow at last”) also causes their death. That substance is the radioactive isotope cesium 137, deadly toxic.

The tone of this section is sharp, direct and often painful, particularly for me the poem “Christmas in Kosovo” (p. 57), an account of the result of the war in the Balkans. The verses unfold the horror of the conflict with brutal clarity:

“One of the men was found in the courtyard,

decapitated, and so far his head

remains missing. Many had been shot

at close range, after the solider pricked them

with machetes and brass knuckles. Later,

the women were raped, and in some cases

their bones were broken.”

That strongly contrasts with the moment in which the poet is witnessing those horrors (soon after Christmas): a time of hope for the coming of Christ, to which Coulehan alludes through the reference to Isaiah’s “Prince of Peace” (Isa 9:6 “For a child has been born for us, a son given to us; authority rests upon his shoulders; and he is named Wonderful Counselor, Mighty God, Everlasting Father, Prince of Peace”). That strain between hopelessness and belief, so present in the poem, made me reflect on the very same tension that is often present when coping with a diagnosis of a life-threatening illness.

Finally, the fourth section comprises family memories and meditations on personal experiences. This change of perspective enables the reader to think about health and illness from different angles, gaining a richer and deeper understanding of topics previously considered in other poems. “Fever of Unknown Origin” (p. 79) speaks about the urge to find explanations to events that are often impossible to account for (“I hold to an old script/ that says calamities have reasons (…) Convenient nonsense,/ but sometimes true.”), and about the need to find a cause to gain control over the disease. With the narrator as the patient, the poem is a reflection on the fear of being seriously ill, and the threat that that constitutes to our somehow perceived “ordered” reality.

The exposure and vulnerability that often patients feel while being examined is a topic extensively covered by Coulehan from the perspective of the doctor, but in “Role Model” (pp. 80-1) this matter is beautifully explored from the view of the patient. The detached and factual discourse of the physician contrasts with the feelings of shame of the patient, who just wants to leave and hide away from the clinician: a need that perhaps we have all felt at some point when being exposed in front of a stranger.

Overall, The Wound Dresser is a fascinating journey that takes us through the complexities of life, illness and death; a journey during which the reader has the opportunity to reflect on the tension between the objectiveness that supports the clinical encounter, the doctor’s inner world, and the patient’s humanity, secrets, fears, needs and contradictions. The presentation of clinical encounters, the use of historical figures or events, the look at scenes around the world, and the account of personal memories that Coulehan brings us facilitate a contemplation of health and illness from interesting and varied perspectives, thus enriching the reader’s world and triggering meaningful meditations on the art of medicine.

 

References

  1. Goodnough A. Finding Good Pain Treatment Is Hard. If You’re Not White, It’s Even Harder. The New York Times [Internet]. 2016 [cited 15 August 2016];. Available from: http://www.nytimes.com/2016/08/10/us/how-race-plays-a-role-in-patients-pain-treatment.html?smid=fb-share&_r=0

 

Further Reading

Blackhall, Leslie J., “Cultural Diversity And Palliative Care”, in Chochinov, Harvey Max and William Breitbart (Eds.), Handbook of Psychiatry in Palliative Medicine, 2nd Edition (Oxford: Oxford University Press, 2009), pp. 186-201.

 

 

Film Review: Arab Film Festival

5 Sep, 16 | by cquigley

 

Both films reviewed below will be screened at the upcoming Safar Arab Film Festival at the Institute of Contemporary Arts London, September 14-18

 

 

Before the Summer Crowds, Egypt, 2015, directed by Mohamed Khan

Opening night film for Safar, Institute of Contemporary Arts (ICA), London, 14th September 2016, http://www.arabbritishcentre.org.uk/event/summer-crowds-qabl-zahmet-al-saif/.

In Arabic with English subtitles.

Reviewed by Professor Robert Abrams, Professor of Old Age Psychiatry, Weill Cornell Medical College, New York.

 

The first thing one can say about Mohamed Khan’s acidly satiric film Before the Summer Crowds is that, notwithstanding its title, it is uncommon summer fare. It is neither light nor breezy, and there’s not much of a plot. The principal characters comprise a trio of clueless, seemingly harmless upper-class individuals who have moved into their “chateaux” in the Egyptian beach vacation community of ‘Blue Beach’ before the regular season has begun. But the viewer is not allowed to retain this initial impression of their harmless existence for long; we are soon let in on the shockingly extensive roster of evils that lies beneath their casual banality: Infidelity, gluttony, corruption, spiritual emptiness, indifference to life, and even a taste for carnage.

First, there’s the pudgy Dr. Yehia (Maged El Kedwany), a man preoccupied with food and sex, whose private hospital scandalously reaps profits by understaffing its medical ranks and hiring inexperienced physicians. Even when he performs a supposedly life-saving cardiopulmonary resuscitation on a beautiful young woman, it is clear that his own sexual gratification is being addressed simultaneously. Yehia’s wife Magda (Lana Mushtaq) is the very personification of emptiness, attempting to sate that void by gorging herself on peanut butter. Magda owns an inherited chateau—a facetiously pretentious name for a beach cottage–in the ‘first row’ of the seaside community, a distinction of which she is inordinately proud and one that she believes places her apart from the ordinary parvenus who arrived at ‘Blue Beach’ more recently. Magda tolerates Yehia, but there is no sense of love between them, not even lust. We see Magda meditating, but there’s nothing spiritually meaningful about what she does—her mind is already empty.

In the course of the film, Yehia becomes involved in a mutual attraction with Hala (Hana Shiha), a young mother who is uninterested in her children and uses her chateau as a trysting place for a rendezvous with Hesham (Hani El Metennawy), her narcissistic B-movie actor-lover. (This fact gives a rather smarmy double meaning to the name ‘Blue Beach’). When Hala learns that Hesham has been unfaithful—no great surprise—she finds common ground, albeit on very shallow soil, with Yehia. They flirt with the idea of having an affair unbound by any conscience or moral codes.

Yehia is at once grotesque and immature, but one is gradually made to understand that his immaturity is far from victimless. His patients are cheated, a court case of medical negligence case is underway; his wife is cheated on; and he sleeps drunkenly as Magda’s pet parrot—the only creature she seems to love—is set upon by cats. It is not the feline hunting instinct that is highlighted in that scene of carnage but Yehia’s indifference. Even Yehia’s preparations for a festive dinner with freshly caught fish seem more like a bloody massacre and an extravagant waste of marine life than a demonstration of his culinary skills.

The working-class young man, Gom’aa (Ahmed Dawood), the resort bell-boy, is seen by Yehia, Magda and Hala as a dispensable entity to be treated with barely hidden condescension. Gom’aa is mainly useful for errands, watering the garden when Yehia doesn’t feel like doing it himself, and fetching things for Hala.

Not a great deal happens in Before the Summer Crowds; but it somehow leaves the viewer with a surprisingly strong impression of sadness and regret. All of the characters are presented as prisoners in different ways of this gated community, unable to move beyond its strictures. The only exception is Gom’aa, a young man who comes from another world looking for his ‘Shangri-La’ in ‘Blue Beach’. Yehia, Magda and Hala have material abundance, sex and food, but are utterly bereft of passion or purpose. The lives of these principals—again save for Gom’aa—are so pathetically empty and loveless that the compassion of the viewer for these otherwise contemptible individuals is paradoxically elicited. How? The key is in the extraordinary acting, where we are unwittingly induced to experience emotions that should belong to the characters but do not; in a way, it might be said that this is the hallmark of all excellent acting.  Here, in the subtly played role of Dr. Yehia, Maged El Kedwany (http://gb.imdb.com/name/nm0444324/) demonstrates why he is considered one of the finest contemporary character actors in the Arab world. Although I have been told that Before the Summer Crowds is not typical of the films of the late Mohamed Khan (http://blogs.bmj.com/medical-humanities/2016/08/01/mohamed-khan-a-tribute/), this deceptively non-action film skillfully not only skewers the bourgeois vacationers of Blue Beach for their corruption and emptiness, but it also lets us feel the sadness of their lives.

Address for correspondence: rabrams@med.cornell.edu

 

Borders of Heaven, Tunisia, France, United Arab Emirates, 2015, directed by Fares Naanaa

ICA, London, Saturday 17th September 2016

http://www.arabbritishcentre.org.uk/event/safar-2016-borders-heaven/

In Arabic with English subtitles

Reviewed by Dr Khalid Ali, Screening Room editor, Medical Humanities

 

Recently, Tunisian cinema has become an artistic force to be reckoned with, As I open my eyes winning best director for Leyla Bouzid in Dubai International Film Festival 2015 (http://www.arabbritishcentre.org.uk/event/safar-2016-open-eyes/), and Hedi opening Berlin Film Festival in 2016 (http://www.imdb.com/title/tt5011242/?ref_=fn_al_nm_1a). Borders of Heaven is another compelling story from Tunisia written and directed by Fares Naanaa.

Samy (Lotfi Abdelli) and Sara (Anisaa Daoud) are a happily married couple with their little daughter Yasmine (Sophie Ghodhbane). Their blissful existence is shattered when Yasmine dies in a drowning accident. Samy is consumed with guilt as he blames himself for Yasmine’s death. Losing the will to live, he wanders aimlessly seeking solace in illicit affairs with random women he meets in the streets.

On the other hand, Sara is determined to fight for survival and a meaningful life in spite of her inconsolable grief. She continues to work daytime and rehearses singing every night with a music group. Sadly, Samy and Sara have become strangers in their household; she wants to re-build their married life, while he is entrapped in his world of anger and hopelessness.

Josephine Jacobsen (https://en.wikipedia.org/wiki/Josephine_Jacobsen) described the devastating effect of a child’s death in one of her poems: ‘’It is a fearful thing to love, what death can touch’’. Borders of Heaven revisits the universal themes of isolation, grief and bereavement after losing a child; themes that were explored in Don’t Look Now, UK, Italy, 1973, directed by Nicolas Roeg, (https://en.wikipedia.org/wiki/Don%27t_Look_Now), and Rabbit Hole, USA, 2010, directed by John Cameron Mitchell (https://en.wikipedia.org/wiki/Rabbit_Hole_(film)). In Don’t Look Now the bereaved couple indulge in an intense sexual relationship to distract their minds from grief, while Samy indulges in alcohol and one-night stands. The estrangement and bitterness that Samy and Sara experience are reminiscent of another bereaved couple’s ordeal (Nicole Kidman and Aaron Eckhart in Rabbit Hole).

Fares Naanaa reminds us of the Kübler-Ross model of the ‘Five stages of grief: denial, anger, bargaining, depression and acceptance’ (1, 2). While Samy is stuck in depression, Sara has accepted the reality of losing her daughter using music and singing as a means to restore her well-being; a form of ‘personalized music therapy’. Echoing themes of Song for Marion, (UK, Germany, 2012, directed by Paul Andrew Williams, https://en.wikipedia.org/wiki/Song_for_Marion), where salvation for a widowed husband came from his engagement in a community music group, Borders of Heaven emphasises the role of music in healing after loss (3, 4).  Sara demonstrates what mental health professionals call ‘psychological resilience’ (5, 6); she channels emotions and words into a creative outlet. Her identity is one of ‘normalizers’; individuals who focus on connecting with friends and community to re-create meaning in their lives after bereavement, while Samy belongs to the ‘nomads; people who are stuck in anger, depression, and loneliness’ (7). Coping with grief after losing a child calls for desperate measures, which can take the form of ‘disinvestment’ in traumatic memories, and moving on with life, which Samy cannot muster.

Both lead actors, Lotfi Abdelli and Anisaa Daoud, give heartfelt performances displaying raw intense emotions that are rewarded by the viewers fully empathising with their tragedy. It is no wonder that Lotfi Abdelli won best actor award in Dubai International Film Festival, 2015, https://dubaifilmfest.com/en/films/41666/borders_of_heaven.html. Borders of Heaven is a universal story of loss, hope and survival.

References

  1. Kübler-Ross, E. (1969) On Death and Dying, Routledge
  2. Kübler-Ross, E. (2005) On Grief and Grieving: Finding the Meaning of Grief Through the Five Stages of Loss, Simon & Schuster Ltd
  1. Khan W U, et al 2016. Perceptions of music therapy among healthcare professionals. Med Humanit 42: 52-6. http://mh.bmj.com/content/early/2015/12/11/medhum-2015-010778
  2. Moss H, Donnellan C, O’Neill D, 2012. A review of qualitative methodologies used to explore patient perceptions of arts and healthcare. Med Humanit 38: 106-9. http://www.ncbi.nlm.nih.gov/pubmed/22893595
  3. http://www.tandfonline.com/doi/full/10.1080/10803548.2015.1126142
  4. Bonanno, George A. Have we underestimated the human capacity to thrive after externally aversive events? American Psychologist 2004; 59 (1): 20-8.
  5. http://psychcentral.com/blog/archives/2011/11/13/the-5-ways-we-grieve/

Address for correspondence: Khalid.ali@bsuh.nhs.uk

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