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The Forgiveness Project: Stories for a Vengeful Age

26 Apr, 15 | by Deborah Bowman

Images of Eva Kor embracing former SS guard, Oskar Groening, at his trial in Lueneberg this week have been shared on social media and in newspapers worldwide. These images, and the responses to them, reveal much about the complex, surprising, inspiring and challenging, sometimes even threatening, nature of forgiveness. Our relationship with forgiveness, collective and individual, is always nuanced and often ambivalent. It is a slippery, shape-shifting concept that rarely exists without an undercurrent of emotion. Forgiveness can be experienced as both restorative and undermining. It may be perceived as noble and a betrayal. We may aspire to it even as we fear it. Forgiveness is a force that may be resisted or harnessed or, perhaps more often than we acknowledge, both.

 

Few have thought more about forgiveness than Maina Cantacuzino. Ten years ago she founded The Forgiveness Project. Last year, saw a series of outstanding events to celebrate a decade of its work culminating in the publication of a book – The Forgiveness Project: Stories for a Vengeful Age. It is a remarkable text that manages in a slim volume to capture the significance and unique approach of The Forgiveness Project and, in doing so, captures why its work matters more than ever.

 

Central to the book and to the work of The Forgiveness Project are stories. Those stories offer an unmediated insight into this demanding, elusive, inspiring and troubling thing we call ‘forgiveness’. It provides space, without judgement or commentary, for people to reflect on and to share what forgiveness means for them.

 

It is these narratives that form the basis of the book, although Marina Cantacuzino’s introductory essay – “As Mysterious as Love” – is an outstandingly thoughtful, and thought-provoking, exploration of forgiveness and her own personal and professional relationship with it. The book also carries two rich and insightful forewords from Desmond Tutu and Alexander McCall Smith. Yet, it is the forty individual stories that follow the introduction and forewords that form the essence of this unique work.

 

Some of those who come to The Forgiveness Project are well-known people whose capacity for compassion and empathy towards those who have caused devastation has prompted fascinated media attention across the world. Others are less familiar names but their stories are equally urgent and compelling. There is neither formula nor any sentimentality to be found. Anyone seeking sentimental salve will be disappointed. Nor do tropes of heroism or survival occur often. What is offered instead is much harder and ultimately more rewarding. These are accounts that are authentic, sometimes painful, often surprising and always affecting.

 

It is not merely the content of these stories that is noteworthy. The form reflects the discomforting and urgent nature of the tales told. All the individual contributions are short, few extend beyond five pages and the language is direct, plain and unflinching. There is force in the form. It propels the narrative, unadorned and untamed, searing each account in our memories and unsettling our own perceptions of forgiveness. The stories are presented with little in the way of preamble and often begin at points of loss, crisis and despair. The ways in which each of these accounts breaches the reader’s consciousness reflects the nature of the experiences described. These stories, like the events they relate, arrive unbidden and unexpectedly, without warning or invitation. They interrupt and disrupt. The language is spare, sometimes even brutal, and simple belying their daunting legacies. These are collisions with strangers that can change the direction of a life, or at the least, the beliefs one holds about a life.

 

These stories reveal that the force of forgiveness is often experienced viscerally. Its charge is both negative and positive. Within the book, there are no homilies or sermons about its normative value or otherwise. It is simply there: unfiltered and demanding our attention. Whether it is resisted, embraced, explored or ignored, its force cannot be avoided. A number of contributors note that it may be easier to define forgiveness by what it is not and, in so doing, they challenge much of the received wisdom about what constitutes forgiveness and why it matters. Others are less interested in definitions and the boundaries of the concept. All those who have contributed to the book attend to meaning in all its infinite variety. These are fluid explorations for alongside the meditations on forgiveness, are reflections on what it means to have hope, to be loyal, to restore dignity and ultimately to be human. That these ideas emerge from the rubble of lives shattered by loss, cruelty and destruction is not only intensely moving, but serves as testament to Marina Cantacuzino’s transformative work both in creating this book and leading The Forgiveness Project.

Prof. Deborah Bowman

Editor, Medical Humanities

St George’s, University of London

Email: dbowman@sgul.ac.uk

Twitter: @deborahbowman

 

Sarah West: Film Review ‘Wild Tales’

13 Apr, 15 | by Ayesha Ahmad

What separates us from living like animals? And what calamity or force does it take to unleash our primal instincts?

 

“Wild Tales” is a compendium of satirical short stories about the pain and pressure points of modern 21st Century life and specifically what happens to the Latin spirit under duress. What delirious lengths do we go to when the pressure of injustice reaches boiling point and something inside us snaps, when all social constraints are abandoned and our spirits are liberated to express our hidden rage and seek bloody revenge. It is a wild ride, visually exciting, full of imaginative twists, and not a breath of the script is wasted.

more…

Franco Ferrarini: Film Review ‘Still Alice’

13 Apr, 15 | by Ayesha Ahmad

Alice Howland (Julianne Moore) is a good-looking fifty-year-old successful professor of linguistics; her loving husband (Alec Baldwin) is a brilliant research physician, she has three beautiful children, a brownstone in the Upper West side and a house at the Hamptons. This is the perfect stage for an impending disaster; in fact after some episodes of forgetfulness, a medical work-up gives the disaster a name: early-onset familial Alzheimer’s disease. From then on directors Richard Glatzer and Wash Westmoreland depict the relentless downhill course of the disease, sparing the viewer only its excruciating terminal stages.

more…

Ayesha Ahmad: Maslaha Workshop for Medical Students: Practical implications of working with diverse communities

1 Apr, 15 | by Ayesha Ahmad

Narrative is an increasingly potent concept for medical educators; developed as a tool to un-cover the patient experience as well as to illustrate the nuances where empathy has a place to fill the gap between the patient and their doctor.

Medical humanities, then, has an integral role for students learning how to become a doctor; and not just merely a doctor; but ‘Tomorrow’s Doctor’ as envisioned by the General Medical Council.

Narratives require that there is space especially within the clinical encounter to be expressed and received. Of course, medical practice elicits narratives containing some of the most significant elements of the human condition. As well as the narratives being diverse encompassing different beliefs surrounding the meaning of life, death, illness, and health, then, so are the narrators. This means that it is necessary for doctors to be trained in perceiving and receiving another person’s story. This is a moral endeavour and also one of justice in the context of a healthcare system that is based on equality and non-discrimination.

more…

The Reading Room: A review of ‘The Development of Narrative Practices in Medicine c.1960-2000′

1 Apr, 15 | by cquigley

 

The Development of Narrative Practices in Medicine c.1960-2000

Jones E M, Tansey E M. (eds) (2015) Wellcome Witnesses to Contemporary Medicine, vol. 52. London: Queen Mary University of London.

 

Reviewed by Ben Chisnall, Medical Student, King’s College London, UK

 

“Narrative medicine” is a term used to refer to a number of analytical and interpretative approaches towards medical practice and interactions between patients and doctors. Its remit is broad, and encompassed within its boundaries are examinations of the personal and professional stories of doctors and patients, the sense-making processes of medical discourse, literary representations of medicine and its practitioners, and the scrutiny of medical forms of writing. Yet it remains a nebulous term, and this book – a transcript of the Wellcome Witness Seminar held at Queen Mary, University of London in June 2013 – brings together many of the individuals who have driven the development of narrative medicine studies in the UK, USA and Europe to provide insight into the scholarly currents which have shaped the field as it stands today.

The book takes the form of a discussion in which a series of narrative accounts are provided by academics and clinicians, many of whom can be regarded as protagonists of the narrative medicine movement. These narratives chart the chronological development of narrative medical studies and the reasons behind its integration into universities and medical schools. What comes across as a major concern of those involved is the desire to better hear the voice of the patient, and to incorporate the patient’s perspective into the thought processes of doctors.

The discussion begins in the 1960s and 1970s, with the introduction of humanities academics into US medical schools. The two main reasons for this, the book suggests, were the desire to provide a more balanced education for medical students, and – as Professor Kathryn Montgomery explains – to “keep [students] interested in patients as they went through the great grinder.”

What is hinted at but not answered in the discussion is whether the interest in what is now referred to as “patient-centred care” within the medical profession prompted a reaching out towards the humanities, or whether the development of narrative medicine and medical humanities departments drove the medical interest in understanding the patient’s perspective. One suspects that these explanations are both correct, and that a gradual alignment of interests between clinicians and humanities academics led to a shared interest in narrative practice in medicine.

The book also touches on larger social trends which may have driven and been driven by increasing interest in narrative medicine. The growth in popularity of celebrity illness memoirs – examples given in the text by Professor Arthur Frank include the Newsweek journalist Stewart Alsop’s column about his leukaemia, and the personal accounts of breast cancer by journalist Betty Rollin and First Lady Betty Ford – indicate a growing desire to hear the voice of a patient and their experiences and interpretations of their own disease and interactions with the medical profession. A recent and useful regular addition to the British Medical Journal entitled “What your patient is really thinking” is a good illustration of how patient voices have come to be valued and their experiences seen as enlightening both for doctors and for lay readers and listeners.

Alongside the development of narrative medicine has been the establishment of medical ethics as a field of study in its own right, which the book identifies as a parallel and reinforcing influence on narrative medicine. Literature and narrative can be used to apply ethical concepts in practical situations, and stories can provide the shift in perspective needed to understand complex ethical dilemmas. Yet as Arthur Frank highlights in the discussion, medical ethics as a discipline does not capture the element of suffering inherent in narratives of illness; this is where narrative medicine can act as an influential force on ethics.

Whilst these developments were happening in the English-speaking academy, narrative medicine in mainland Europe – as described here by Professor Jens Brockmeier from the American University of Paris – looked more towards influences from psychiatry, psychoanalysis and Freud. What emerges is the sense of the ideas behind psychoanalysis working their way into the medical academy through the growth of psychiatry as a scientific discipline during the 20th Century. So too is the study of hermeneutics, which runs through much European analytical literature, applied to the process of medical interpretation: of texts, tests and tales of patients.

The discussion in the book is far-ranging in theme and chronology, and contributions are well marshalled by Professor Brian Hurwitz in the chair. It provides valuable and thought-provoking insights into the beginnings of the narrative medicine movement, and the various and geographically diverse voices captured in the text give a heterogenous feel befitting the nature of the subject under consideration. Although narrative medicine is currently a specialised area of study, the topics under discussion in the text are accessible and applicable for those unfamiliar with the field.

Reading the book brought to mind the influence of those principles at the heart of narrative medicine on the reporting of and reactions to two scandals in the NHS which have been in the public consciousness recently – the Francis Report into the standards of care at the Mid Staffordshire NHS Trust, and the revelations of abuse at a number of NHS hospitals by Jimmy Saville in the 1960s and 1970s. Mention is made in the discussion of a “crisis of compassion” in the modern NHS, and the poor standards of care at Mid Staffs were uncovered when patient voices – many of whom were elderly, and therefore less likely to command attention – were listened to and acted upon. Similarly, the rise to prominence of the voice of patients after years of dismissal led to an investigation into Saville’s abuse. These are prime illustrations of not only the impact that narrative can have on modern healthcare, but also on how the ideas behind narrative medicine delineated in this book have become widespread and valued.

Medicine Unboxed: Students 2015 – An Invitation to Participate

24 Mar, 15 | by Deborah Bowman

Medicine Unboxed: Students 2015 – Call for Participation

 

Medicine Unboxed aims to inspire debate and cultural change in healthcare. Medicine today exists at a time of extraordinary scientific knowledge and therapeutic possibility but faces challenging moral, political and social questions. Medicine Unboxed engages the general public and healthcare audiences with a view of medicine that points to human experience, ethical reflection and political debate alongside scientific achievement. We believe the arts can illuminate this perspective, inspire conversation on the values implicit to good medicine and foster a sense of awe and wonder. Our annual events – Unboxed (2009), Stories (2010), Values (2011), Belief (2012), Voice (2013) and Frontiers (2014) – attract audiences of over 300 people, and draw writers, politicians, philosophers, musicians, performers, theologians and artists into dialogue with clinicians and patients. These events are theatrical, moving and challenging. Our event this year, on 21-22 November in Cheltenham, explores Mortality.

 

Now in its third year, the Medicine Unboxed: Students event brings students of the arts, health and medicine together to share, explore and converse, drawing on the unique perspective and experience of being a student or in the early stages of a profession. Medicine Unboxed: Students 2015 takes place on the afternoon of Friday 20th November and we are seeking proposals for participation in this event and to be interns for Mortality.

 

Medicine Unboxed thrives on diversity and inclusivity. We are particularly keen to welcome students (undergraduate or postgraduate) from all backgrounds, including (but not limited to) art, drama, music, medicine, literary studies, philosophy and allied health subjects. You can submit a proposal in one of four broad categories:

 

  1. Provocations and Debates– proposals are likely to focus on a contested aspect of health, illness and its treatment and/or to explicitly engage with multiple points of view;
  2. Exhibitions and Performance– submissions in this category are likely to be creative e.g. poetry readings, monologues, excerpts from plays, creative writing, musical performances, stand-up comedy, art exhibits, short films etc.
  3. Workshops and Interaction– proposals may include experiential activities such as drawing, creative writing, singing and voice activities, improvisation etc or an interactive approach to a question or concept.
  4. Conversations– submissions in this category are likely to take the form of short papers or prompt material presented to, and discussed with, the audience.

 

Proposals may be from individuals or groups. They should be no longer than 500 words and include the i) title, ii) format, iii) names and affiliations of the people involved and iv) a summary of the contribution proposed. You should also indicate in which category you would like your proposal to be considered.

 

Please email your proposal by 6 July 2015 to Dr. Sam Guglani (sam@medicineunboxed.org). All proposals will be reviewed by the advisory group for Medicine Unboxed: Students and decisions will be communicated by 20 July 2015. 8 winning entries will be selected to present at Medicine Unboxed: Students (20th November 2015) and to act as interns for Mortality (21-22 November 2015) with travel and accommodation for the weekend included as part of the award.

 

 

Follow:             @medicineunboxed and @MUstudents

Explore:           http://mustudents.wordpress.com/ and http://medicineunboxed.org

Join:                 https://www.facebook.com/groups/175072369272118/?fref=ts

Mail list:          https://www.facebook.com/medicineunboxed/app_100265896690345

 

 

ePatients: The Medical, Ethical and Legal Repercussions of Blogging and Micro-Blogging Experiences of Illness and Disease – Call for Papers and Conference Details

22 Mar, 15 | by Deborah Bowman

Queen’s University Belfast, 11-12 September 2015 Call for Papers

Referring to the growth of online patient-initiated resources, including medical blogs, the BMJ noted in a 2004 editorial that we were witnessing ‘the most important technocultural medical revolution of the past century’. Ten years later, the controversy caused by Bill Keller’s opinion piece in the New York Times (‘Heroic Measures’, January 2014) and a blogpost on the Guardian US website criticising Lisa Bonchek Adams’s decision to tweet her experience of breast cancer, remind us of the ongoing sensitivities surrounding online patient narratives and the complex relationship between the world of medicine and social media. Emma Keller, the freelance journalist (and wife of Bill Keller) who questioned Adams’s use of twitter to discuss terminal illness, wrote the following: ‘Should there be boundaries in this kind of experience? Is there such a thing as TMI? Are her tweets a grim equivalent of deathbed selfies? Why am I so obsessed?’ Adams, in emails to the Guardian, said that the column was ‘callous’ in its treatment of her and noted that the blogpost was riddled with inaccuracies and quoted a private direct message without permission.

As debates on the ethics, dynamics and even legal repercussions of online patient narratives become more prevalent, an international, interdisciplinary conference at Queen’s University Belfast, hosted by the Health Humanities Project Research Group at the Institute for Collaborative Research in the Humanities, will focus on how those with life-threatening or incurable illness use social media, as well as the medical, ethical and potential legal consequences of online accounts of pain, suffering and the clinical experience. We welcome paper proposals dealing with ePatient accounts from a variety of countries and cultures which address the following questions:

  •   What does the rise in social media (“web 2.0”) participation by patients tell us about the ways in which the growing influence of e-patients is challenging the power structures of traditional healthcare and, as a result, proving contentious?
  •   In what ways might social media narratives of illness be seen as a useful source of information for medics? What, conversely, are their limitations?
  •   How do patients influence their online followers, and vice-versa?
  •   What are the ethical issues involved in documenting ‘the public deathbed’?
  •   What are the potential legal consequences of publicly chronicling the clinical experience?

250-word proposals for 20-minute papers (or three-paper panels), in English, should be sent to Dr Steven Wilson by email attachment at the following address: steven.wilson@qub.ac.uk. The deadline for receipt of proposals is Friday 3 April 2015.

Art in Arthritis by Nancy Merridew

22 Mar, 15 | by BMJ

 

 

I called Marco from the waiting room.

 

Everyone looked waxen under the fluorescent lights of Rheumatology Clinic. His olive skin looked grey. He rose like a grapevine on the trellis – thickset but gnarled through the seasons.

 

Marco helped his wife with her handbag and they walked together. Her gait was robust; his was antalgic and unhurried, though slower than he’d have liked.

 

In the consulting room we shared our introductions. I explained that I was aware of his medical history and asked “what are your biggest joint troubles today?”

 

Marco’s molten voice was rounded with a beautiful Italian accent and 80 years of life.

 

Apologising in fluent English Marco said that he didn’t speak English well and that it’s important to “talk the talk” of the doctors.

 

He looked down, reached into a shopping bag, and handed me three sheets of drawings.

 

I was stunned by beauty, utility, and clarity.

 

Brown ink outlined each picture, backfilled with camel watercolour. One image revealed the face of a younger man and the muscular shoulders of youth – his mind’s eye self-portrait.

 

Marco nodded to confirm that he had drawn them all.

 

Each drawing was anatomically correct and swelled from the parchment like parts of an amputee ghost. In some, his bones were bare. In others Marco had blended superficial features of skin with deeper structures of the appendicular skeleton.

 

A left hand floated on one page, like Adam’s in his Creation on the Sistine Chapel ceiling. Words – “Pain here” and “Here too” – were anchored by lines drawn to the hand, portraying metacarpophalangeal and proximal interphalangeal pain.

 

Figure.1_Hand.Shoulder_BMJ

Figure 1. Annotated drawings of right shoulder, face, and left hand:

  • “Pain here” [SHOULDER]
  • “Pain here” [5th METACARPOPHALANGEAL JOINT]
  • “Here too” [2nd METACARPOPHALANGEAL JOINT]
  • “Pain here” [FINGER]

 

Six weeks earlier a rheumatologist had diagnosed Marco with recurrence of polymyalgia rheumatica, with shoulder and small joint features, and with a possible component of new onset rheumatoid arthritis. Recurrent carpal tunnel syndrome was diagnosed in his right hand.

 

On the other pages Marco had drawn his hips, knees, and feet, and annotated their aches with cursive writing.

 

These bones it seems that they are coming apart. When I walk for about ¾ of an hour then it start to give pain. Swells up and gets quite hot. The knee.

 

Figure.2_Knee.Foot_BMJ

Figure 2. Annotated drawings of foot and knee:

  • “Pain here especially at night.” [KNEE]
  • “These bones it seems that they are comming (sic) apart. When I walk for about ¾ of an hour then it start (sic) to give pain. Swells up and gets quite hot. The knee.” [KNEE; TIBIOFIBULAR JOINT]
  • “Pain here last for days on both feet. Not all the time” [TALUS]

 

Marco was seen in the hospital’s Orthopaedic Clinic for severe osteoarthritis of his knees.

 

A carpenter, who still bent those knees to work, Marco explained that he once did a Fine Arts degree to support his business. Beyond that expertise, his careful handling of the autographed pictures revealed an artist.

 

The edge of one page cut through the word “foot” at “foo” which perhaps reflected Marco’s life.

 

Born during the Great Depression he was of the frugal generation – practical, resourceful, industrious. I wondered if Marco had ever rationed paper as a luxury, each sheet precious and saved for handsome cabinet designs.

 

Perhaps as an artist, unwilling to share flaws, he had cropped a larger page of sketches.

 

Figure.3_Hip.Foot_BMJ

Figure 3. Annotated drawings of right foot, pelvis and right lower limb:

  • “Both feet hurt at times” [FOOT]
  • “Pain in here sometimes not all the time” [HIP JOINTS BILATERALLY]
  • “Right leg. Pain here” [FEMORAL HEAD, TIBIAL PLATEAU]

 

I was enthralled.

 

Marco’s eyes danced like bubbles from the surface of Prosecco – the muted pleasure of artistic pride.

 

Already he had offered his pictures to me three times as a gift.

 

Yet I had declined as it seemed too generous. I thanked Marco and encouraged him to keep bringing the drawings to appointments given their clinical value.

 

I completed the history.

 

Marco’s main concerns were steroid-related weight gain, although his arthralgia had improved.

 

As he talked I noticed subdued hand gestures. Given his Italian heritage, perhaps Marco suffered a cultural version of locked-in syndrome from the pain that restricted his upper limbs.

 

After completing the physical examination, I liaised with my registrar about Marco’s clinical plan. In a makeshift gallery behind the consulting suites I showed his artworks to the rheumatologists.

 

They advised that I could keep the pictures, and to take photocopies for the medical record. I made an extra copy either for me or for his art portfolio.

 

I returned to the clinic room. Marco’s wife, who had been silent, was keen to hear the consultants’ opinions of his drawings.

 

She beamed on learning that they were unanimously said to be “the most beautiful ever seen in clinic”, and particularly enjoyed by the Head Professor of Rheumatology.

 

Again Marco offered his pictures and this time I accepted with delight.

 

Smiling, he received his own copies as I explained his treatment changes and follow-up plan. We shook hands. Those aching hands created beauty and conveyed exceptional insights.

 

I watched as he left with his wife and wondered about their lives, leaving Italy to bring their charisma to Melbourne.

 

Two days later I framed the drawings – an exquisite medical document and gift. They hang in my home and evoke Marco’s grace, eloquence, and vitality.

 

* * *

 

Acknowledgements and Postscript

 

Marco, a pseudonym, has consented to the release of his artworks for the purposes of this article. See Figures 1, 2, and 3. Sincere thanks to the patient for his generosity and insights.

 

Thanks to Dr Thomas Lawson Haskell BMBS for his excellent photography of the drawings.

 

Correspondence: Dr Nancy Louisa Gwen Merridew BA BSc MBBS DTMH

Basic Physician Trainee, Launceston General Hospital

PO Box 1328, Launceston, Tasmania, Australia 7250

Nancy.Merridew@gmail.com

The Reading Room: The Wellcome Book Prize

9 Mar, 15 | by cquigley

 

The shortlist for the Wellcome Book Prize was announced today (http://wellcomebookprize.org/)

Awarded annually, and open to works of fiction and nonfiction, the prize focuses on books that have some aspect of medicine, illness or health as their central theme.

This year’s shortlist includes the following six titles:

  • The Iceberg by Marion Coutts
  • Do No Harm by Henry Marsh
  • All My Puny Sorrows by Miriam Toews
  • Bodies of Light by Sarah Moss
  • The Incredible Unlikeliness of Being by Alice Roberts
  • My Age of Anxiety by Scott Stossel

The Reading Room has already featured reviews of The Iceberg (http://blogs.bmj.com/medical-humanities/2015/01/09/the-reading-room-a-review-of-marion-couttss-the-iceberg/) and Do No Harm (http://blogs.bmj.com/medical-humanities/2015/02/10/the-reading-room-a-review-of-henry-marshs-do-no-harm/)

Reviews of the remaining four shortlisted titles to follow, before the winner is announced on April 29!

The Reading Room: A review of Henry Marsh’s ‘Do No Harm’

10 Feb, 15 | by cquigley

 

Reviewed by Eoin Dinneen, Academic Clinical Fellow, University College London Hospital

 9781780225920

Do No Harm is a remarkably simple book. So much so, The Guardian (the book was short listed for The Guardian ‘First Book Award’) asks, ‘Why has no one ever written a book like this before?’ Each chapter’s starting point is a real life case. The clinical and extra-curricular vignettes recited allow the reader the privilege of being a fly-on-the-wall during moments of incredible personal and professional strain, sometimes during frank disaster, and occasionally during enormous relief and hilarity. In total, the book makes up a lean, unadorned, honest memoir of just some of the emotional thrills and surgical spills from a life spent in a busy tertiary neurosurgical unit. There is no twisting, confluent, fictional, engineered storyline because the quotidian of Marsh’s operating theatres, clinic rooms and foreign trips provides a surplus of heroes and heartache to sate the appetite of even the most demanding reader, publisher or dramaturge.

Do No Harm is beautifully written. Most impressively and intimately so when Marsh is describing what a living functioning brain actually looks like. Many doctors will have encountered cadaveric specimens as medical students, but their warm, electrochemically fizzing, ‘live’ predecessors evoke true wonder, especially when the reader (or the patient for that matter) is in the hands of Marsh and his remarkable familiarity, structurally at least, with our grey matter.

The illuminating passages detailing neurosurgery are intense and intensely bright. Time seems to slow with each passing pulsation nervously noticed. Marsh describes the clean and perfect cerebral anatomy; the glistening dark purple veins, the clear liquid crystal CSF, the flashing strands of arachnoid, the smooth yellow surface of the brain and the minute bright red blood vessels. Despite repeating modestly, both in the text and in promotional work around the book’s publication, that neurosurgery is but a simple matter of thuggish hole drilling and the such, this is brain surgery. Intricate, terrifying, compelling brain surgery. The minute topography of what lies inside the human skull under the meninges sparkles and moves almost as much for the reader as we feel it continues to sparkle and dance dangerously for Marsh. When Marsh was a student at the Royal Free Hospital, the doors to the neurosurgery theatres were closed to juniors. Now at St George’s Hospital, medical students are still not allowed into the neurosurgery clinic consultation rooms. Do No Harm briefly opens the door to the world of neurosurgery, doors traditionally closed to doctors let alone to patients.

If describing the anatomy of the brain should be considered ‘home turf’ for Marsh, what is even more remarkable is the profound illumination he pours on humanity when he turns his literary attentions to his patients as people, rather than brains. Cartesian duality complexly and complicitly underpins all the surgical stories, but on a simpler level the book is rich in revelatory illustrations of the doctor-patient relationship and of plain, complicated, sometimes nonsensical human behavior itself. As a surgical trainee myself, it has often vaguely agitated the foreground of my mind during busy days how few difficult questions prospective surgical patients ask prior to their surgery. Marsh notices this discrepancy also, but with characteristic flair and simplicity born of experience he highlights that, ‘as patients we are deeply reluctant to offend a surgeon who is about to operate on us.’

Also worth noting are Marsh’s musings on modern hospital care. When caring for his own dying mother in the family home, Marsh reflects on the difference between his mother’s death and that which is afforded the vast majority of dying patients who are ‘cared’ for in hospitals, care homes, nursing homes and palliative care centres. With trademark honesty Marsh points out that hospital workers are ‘caring professionals whose caring expressions (just like mine at work) will disappear off their faces as soon as they turn away, like the smiles of hotel receptionists.’ Marsh’s uncompromising frankness to tell it how it is makes for unsettling yet categorically undeniable reading for today’s healthcare professionals. Sadly, it may ring a bell for some of our patients too.

Amidst the achingly tense surgery and desperately sad patient case histories (so tragic that when Marsh met the producers of Holby City he dissuaded them from creating a central role for a neurosurgeon because his tales were so forlorn), there is much more to be taken from this book. Do No Harm, I suspect, will come to be seen in the future as a time capsule of the NHS of 2014. Though many of the patient and surgical anecdotes are picked from the many years of Marsh’s medical career, the book is predominantly written in the current day: the 21st century NHS with all its vaunted idealism, sheer enormity, HR directives, staff diversity, exasperating IT systems and senseless inefficiencies. Yes, the NHS we know, work in and die in. Marsh’s caustic commentary of the systemic incompetence and his grumbling subversive distrust of management will of course be familiar to many, but it is here much more cleverly penned than our daily flippant, flapping volleys.

On that note, though they provide the lightest and most sardonic moments in Do No Harm, Marsh’s thoughts on modern hospital management and individual managers is (with one notable exception involving the Chief Executive in Chapter 13) quite adversarial and sometimes pithy. Marsh is not unique in this respect; in fact his attitude again captures the prevailing mood amongst his Consultant colleagues nationwide. However, in the same way that Marsh tells us how he idolized and imitated his great bosses, we junior surgeons are highly likely to follow their lead in a similar apish process. It is not at all a surprise, therefore, when popping into the Doctors Mess, or passing even the most junior of doctors chatting in the corridor, to hear them complaining bitterly about managers they have had no real recourse to come into contact with yet. One feels that Marsh writes of his surgical mistakes in a genuine attempt to inform his successors so that such mistakes are not lost to a graveyard of long forgotten medical errors and repeated unwittingly. If the book is meant to be instructive in any respect for junior doctors, should there not also be some leadership on how to create harmonious interactions with hospital managers who are, lest we forget, our colleagues, and the people who run our hospitals and our healthcare system?

Do No Harm presents itself as a collection of parables, with Marsh himself cast in a panoply of roles, from the international surgeon superhero in Ukraine to the local friendly south London doc who cycles to work like the village vicar. He writes himself as a naughty schoolboy figure furtively struggling against the hospital establishment, and then challenges this by impatiently chastening a scruffy, insouciant junior doctor at the morning meeting like a schoolmaster from his days at Westminster College. Marsh represents an authoritative member of the modern medical milieu but also, movingly, puts himself on the ‘other side’ as a family carer.

Marsh does not dwell on religion or on God. He seems to intimate in a variety of ways that organized religion is not how he makes sense of the cosmos. After an ill-fated operation, which goes catastrophically wrong in the 18th hour of surgery, Marsh renders a young man paralyzed. When he breaks the terrible news to the waiting family, the patient’s mother beseeches Marsh to remember her now quadriplegic, mute son in his prayers. The neurosurgeon does not pray within the context of Do No Harm. Instead, a man of letters, of learning and of neuroscience, in this startlingly honest book about ‘Life, Death and Brain Surgery’, Marsh remembers his patients.

Do No Harm by Henry Marsh. London: Phoenix (an imprint of the Orion Publishing Group Ltd), 2014

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Medical Humanities

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Latest from Medical Humanities

Latest from Medical Humanities