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doctors as patients

Romanticizing Tubercolosis

21 Mar, 17 | by amcfarlane

Radu Jude (Director of ‘Scarred hearts’) and the Screening Room Editor of Medical Humanities, Khalid Ali, met at the London Film Festival, October 2016.

Our screening editor, Dr Khalid Ali (Khalid.ali@bsuh.nhs.uk), here writes about the importance of Romanian director Radu Jude’s new film Scarred Hearts (Romania, 2016) and interviews him at the London Film Festival in the podcast included below.

Each year on the 24th of March, several organizations around the world celebrate ‘International Tuberculosis Day’. It serves as a timely reminder that TB still remains an international epidemic claiming the lives of an estimated 1.4 million people, making TB one of the top 10 fatal diseases, and the emergence of 480,000 multidrug-resistant TB cases annually according to the Global Health Observatory data report- 2015. Before ‘Streptomycin’ was discovered as an effective anti-tuberculous drug in 1944, TB was a devastating disease with an inevitable death sentence. Radu Jude, award winning Romanian film director, revisits the TB epidemic in the early twentieth century in Scarred Hearts. The film is based on the life of Max Blecher (1909-1938), a Romanian writer who wrote the book Inimi Cicatrizate based on his own affliction with TB.

Scarred Hearts is a close examination of the life of Emanuel (Lucian Tedor), a Jewish Romanian young man in his twenties from a privileged background in the turbulent times of WWII, who falls ill with Pott’s disease (TB of the spine). Emanuel is admitted to a sanatorium, were he spends years bed-ridden, contemplating life, love, and illness. While meditating and writing his books and essays, Emanuel meets and befriends fellow patients and nurses. His encounters with the sanatorium’s resident doctor are short and traumatic; one such encounter happens when the doctor evacuates an abscess from his back with little analgesia, if any. The days go by slowly in his confined solitary world, while some nights are livened by ‘carnal activities’ with a young, female nurse, and another patient affected by TB. With the war exploding outside, boredom and melancholy set in in the dark corners of the sanatorium. The budding companionship and friendly exchanges with other inpatients over smoking, drinking alcohol, and playing cards, make the sanatorium a safe refuge for creativity in writing literature and composing essays, human interactions, friendships, and love. Some patients even decide to stay in the hospital indefinitely, and take up voluntary roles caring for other patients, showing altruism and human sacrifice. Self-management in chronic conditions is a relatively new concept in medical literature; however, Emanuel in 1930s Romania embodied the essence of self-management in ‘surviving a bed-bound existence with resilience and hope’. The socio-economic dimension of TB in today’s world plays an important factor in making it a universal public health and social challenge. Co-ordinated health and social interventions are as much needed today as they were in the mid 1930s.

Throughout history, TB has been given several names:  consumption disease, The White plague (a seventeenth-century TB epidemic in Europe and North America), Phthisis (a term which appeared in Greek literature around 460 BC, and was used by Hippocrates), Scrofula (TB of the lymph glands), and Pott’s disease. It was also referred to as the ‘Romantic disease’ as a lot of its sufferers were young adults at the time of the Romantic movement in European art, literature, and philosophy. Throughout history several notable literary figures suffered from TB; Jane Austen, Emily Bronte, John Keats, Anton Chekov, Franz Kafka, Khalil Gibran, and George Orwell are some examples. However, Max Blecher stands out in documenting his journey with TB in Inimi Cicatrizate.

It is interesting to note that Max Blecher was studying medicine in Paris when he had spinal TB. He was forced to abandon studying medicine, and become institutionalised in hospital settings until his untimely death at the age of 28. As a medical student and a writer, he had several qualities which are essential in both vocations; keen observation, building a rapport with those around him by actively listening to them, and transforming all those interactions and experience into a coherent form of story-telling. It goes without question that ‘empathy’ was a driving force in his analysis of the physical and emotional facets of illness. He was indeed bed-bound, but his eyes and ears were wide-open to the suffering and misery around him. Documenting his thoughts and philosophy in writing might have helped him stay sane, hanging on to some form of well-being in the bleakest of circumstances. Mother Theresa once said ‘The biggest disease today is not leprosy or tuberculosis, but rather the feeling of being unwanted’. Reminding ourselves on Friday 24th March 2017 of the global impact of TB, its sufferers are no longer alone or unwanted.

Listen to the interview with Radu Jude, director of Scarred Hearts:

Art review: chronic conditions and the digital age

9 Nov, 16 | by cquigley

Changing Lanes: Art in long term conditions in the digital age – new ways to adapt

By Shanali Perera

Rheumatic and musculoskeletal diseases are the largest growing burden of long term disability in the UK, affecting over 10 million adults. The concept of empowering patients to better engage with self-management of their long-term conditions is changing the world at an ever-increasing pace. Incorporating creativity can enhance interpersonal well-being.

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Through my artwork, I aim to reflect my personal experience to raise awareness on ‘Creative empowerment – exploring the healing power of art’. Personal insights as a medic and a patient into integrating creativity, healing & health on the use of creative expression as a tool to face some of the physical limitations & challenges imposed by chronic illnesses. I am keen to tell others of my experiences as they may benefit from incorporating art or similar creative expressions into their own healing. Why not challenge illness dominance? I do so by using digital art.

I am currently a patient under the care of Rheumatology services at the Manchester Royal Infirmary, treated for vasculitis. I used digital applications for artwork to cope with pain, illness experience, adjust to living with vasculitis; to communicate with health providers, family and friends. Prior to ill health retirement, I was a Rheumatology specialist trainee and this journey has indeed been a transformative experience both personally and professionally.

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Copyright © 2016 Shanali Perera

Eight years of numerous A&E and hospital admissions, multiple consultations from various disciplines have given me some valuable insights into a patient’s journey. Chronic diseases can turn one’s life upside down, gradually changing the landscape of daily living. Art can be a refuge for coping with the dynamic shifts in daily routine – accepting role limitations, altering perceptions and regaining some level of control. Creativity gives something to take control of and construct a positive identity. I like to highlight the potential benefits I felt by facilitating self-expression through creativity. Art was a tool for positive reinforcement and reflective thinking for me. I found expression through Art not only represents symbolic aspects of coping but also demonstrates the many facets of emotions and degrees of pain I feel at various points, as a visual narrative. This form of non-verbal communication is effective in helping family, friends and health team gain new insights into often under estimated, emotional/spiritual elements factored into the illness experience. Seeing beyond the illness – creative expression helping to redefine self-identity. I managed to achieve a semblance of normality by starting to set more realistic goals and standards for me around my limitations. From my experience, adapting to find ways around limitations plays a key role in rebuilding confidence and progressing forward. I feel that accepting the shift in roles, reshaping and reinventing one’s self is an essential part to living with a long-term illness.

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People with certain disorders not only have to deal with the general disability of the chronic illness, but also the physical limitation of expressing the “art” that is in their mind. On repeated use my hands become numb and painful, pain radiating to my shoulders. I found the use of digital medium my adaptation as it enabled me to use light touch with minimal effort and alternate hands. Less pain and fatigue became apparent in my hands and arms compared to using a paintbrush on canvas or charcoal on paper. For me, artistic expression was a means of self-exploration to convey how I was feeling. This really helped me to keep the fun side alive and regain a degree of control. This newfound freedom to explore myself through the world of colours and inner creative space, gave rise to my present work.

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Copyright © 2016 Shanali Perera

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Copyright © 2016 Shanali Perera

I think art certainly can be used to explore and represent one’s individual journey -The way chronic illnesses are constantly changing shape, defining and re-defining itself. I feel that this aspect to self-care isn’t advocated to its full potential in people with long-term physical illnesses. There is a lot of scope to develop this further as a holistic approach to care given the wealth of studies illustrating the beneficial effects of integrating creativity and healing in long-term conditions. Present day represents the Digital age where Digital technology in healthcare is continually changing the world at anever-increasing pace. The use of digital medium/applications for creativity, especially for people with limited functional capacity/pain can be a constructive as well as an enjoyable pursuit to explore one’s creative side to cope with day-to-day struggles. Why not put this into wider use in the context of self-management of chronic illness? Let’s take a closer look at our creative space.

Be Visible! Be Heard! See yourself through art.

Correspondence to:

shanaliperera@gmail.com

First impressions only happen once

7 Jun, 16 | by cquigley

 

Fergus Shanahan

 

Eyes smiling, face beaming, the porter rose from his stool to greet arrivals at the cancer centre, each nervously hesitant, staying close to a supporting loved one. With the confidence of a man who enjoyed being good at his job, he paused for those needing directions, reassured us that we were in the right place for our appointment, and then boomed: “Welcome everyone, and good luck to you all today.”

Good start. After that, we didn’t mind inconveniences like waiting for the single working elevator and felt better about whatever unknowns were ahead. The moment was still fresh when we got to the sixth floor. There, we faced a receptionist unable to switch her gaze from a computer to address us. Detached with jaded eyes fixed elsewhere, her outstretched arm dispatched us to an adjacent touch screen to register. We obeyed but the system insisted on a five-digit address code. Bad enough to be labelled ‘international’ as code for not having acceptable insurance, but not having a zip code was a new stigma. Before we could explain, Miss No-Eye-Contact was on the phone staring at some distant point behind us, then back to her screen with a facial expression that said: “Can’t you see! I’m busy.” Bristling a little, I blurted out my son’s details to demand attention. Without the slightest shift in posture, she confirmed our existence in the system with a few flicks of her keyboard. Progress. Then she left us with the unsettling comment: “Hmm, that’s interesting…take a seat and wait while I check with Accounts.” This is not what patients want to hear as they contemplate the prospect of major surgery. No one wants to be that kind of interesting.

Joe shot a warning glance at me “Dad…don’t be rude with this lady. Don’t lose it!”

Lose it! After 8 months of continual worry and stress trying to steer my son through the complexities and decision-making of a young man’s cancer treatment, I was determined not to ‘lose it’. We were overseas in a different healthcare system for a high stakes operation. They were now in charge and I would just have to play it their way. After all, I wasn’t the patient. I was supposed to be the support. So I stayed quiet. Then, the silence was broken, delightfully so, it seemed to me, when an old woman behind us flatly refused to have anything to do with self-registration. Dismissing the technology with an impatient wave of her hand, she snapped at no one in particular in a brash accent: “I’m not gonna do it, I can’t be bothered with that.”

Miss No-Eye-Contact receptionist had met her match.

While waiting, I imagined myself telling anyone seeking my opinion that professional staff within medical offices and hospitals should heed the little things that comfort patients. I would tell them that little things are important. Staff should know that routine for them is crisis for the patient. I would remind them that there is only one opportunity to make a first impression. First impressions are made up of little things. Little things can make a big impression. If the front office experience is poor, anxiety increases and confidence in the rest of the enterprise becomes more doubtful. In other words, if the dentist’s receptionist is a barracuda, don’t expect much pain relief when you get to the back office.

Then, we heard our name called out and we were on our way into the back office.

The interview with the surgeon was probably over within minutes but it seemed much longer. He began with a firm handshake. Then, sitting beside us not across a table, he spoke confidently in clear, crisp, explanatory sentences. These, he must have repeated on hundreds of previous occasions but it didn’t seem that way. He anticipated our questions and acknowledged our sense of urgency.

In the end, the professionalism of the porter that morning and his memorable welcome was the bellwether for what followed. The surgeon’s skill and experienced team determined what was to be a favourable outcome. But something else made a difference and a lasting impression. To borrow from the poet Maya Angelou:  “…people will forget what you said, people will forget what you did, but people will never forget how you made them feel.”

 

Fergus Shanahan, MD, DSc

Professor and Chair,

Department of Medicine,

Director, APC Microbiome Institute

University College Cork,

National University of Ireland

Tel +353-(0)21-4901226  also cell phone 086 280 4881

FAX +353-(0)21-4345300

F.Shanahan@ucc.ie

 

 

The Reading Room: The Other Side of Silence

20 May, 16 | by cquigley

 

The Other Side of Silence_CMYK_cropped

The Other Side of Silence: A Psychiatrist’s Memoir of Depression by Linda Gask.

Vie Books, 2015

Reviewed by Dr Lilian Hickey

There is a shocking, but humane and tender poetry in George Eliot’s lines in Middlemarch which refer to the deafening ‘roar’ of life that might lie ‘on the other side of silence’ in our ordinary day-to-day emotional experiences –  if we only had ears to hear it (or the courage to bear it). We humans spare ourselves, Eliot says, by securely, routinely, tuning out from awareness of the more unmanageable aspects of life – for our sanity’s sake (‘wadding’ ourselves in ‘stupidity’).

Linda Gask takes some of these words of Eliot’s for the title of her memoir, which has a fierce, tenacious, calm and utterly generous sense of commitment in her remarkably frank account of that potentially overwhelming ‘roar’, both in her own life, but also in her accounts of many of her patients’ lives from her long career. Her book sets out to help others through her very personal account of a life beset by periods of severe depression, as well as by episodes of disabling anxiety, difficult obsessional ruminations and even paranoia. Her professional life as an esteemed psychiatrist, researcher and educator has been deeply, tacitly informed by her awareness of her own fragilities, which have included times of almost suicidal desperation, and her story is a compelling one of love, loss, betrayal, kindness, hope and dedication. (And also, tellingly, of some very kind and good doctoring and therapy, hers and others’, along the way)

The bedrock of her memoir rests, as most lives tend to, in the matrix of her childhood experiences, which she brings to life in simple, vivid, often unhappy, detail. Her labouring father always had oil-stained hands, from long and dangerous hours spent tending to the workings of a funfair ride…his determined and passionate nature has been passed down to his only daughter, who adored him.  She can see how she has become her father’s daughter, and benefited from his ambition for her. His later rages, sometimes violent in her adolescence, and his sudden death while she is in Edinburgh working as a house officer, are for a long time impossible for her to take in. It is years later with the help of her first therapist that she begins to make sense of her relationship with her father and what his loss has meant. (Though she says she can never be sure exactly how proud he might have been of her achievements, praise and pride were not in the family behavioural lexicon). Her relentlessly unhappy, critical, jealous mother is cold and ever-unappeasable, but in the book, the lack of warm maternal care seems especially hard to place – if not describe – in the origins and seams of her very real childhood, and then adult, distress. Perhaps the great tragedy of her family unhappiness however lay in the persistent, mostly silent, tormented obsessive compulsive illness of her younger brother, whose later apparently ineffective psychiatric care is described. The lack of any help or support for his childhood torment and its deeply devastating effect on family life,  seem to have been important factors in her later coming to find in psychiatry a place where she could become the sort of doctor who could bear to hear and think about the roaring of despair.

Gask’s childhood sensitivities to unspoken emotional weathers, and to the fears and distress of others, bring to her professional life a capacity for concern, clear sighted clinical observation and an ability to attend to, and be concerned about, troubled states of mind.  The book is also, amongst its chapters, a reminder of the stresses of undergraduate medical studies, the pressures of long hours as a junior doctor and of what it can be like to work in neglected, down-at-heels psychiatric facilities. The notion of asylum for those is distress is thought about, and often in her story seems much more in evidence in the kindness of professionals than in the tatty surroundings offered to the mentally ill.

The professionals who make a difference to Gask are described candidly – the kind, the solid, the unreliable, the awkward and the wise. We are reminded that the right psychiatrist or therapist can be an astonishing lifeline on the edge of a mental abyss, and over the years her medical and psychotherapeutic relationships have been essential aspects of her own soul-rescuing in times of dread or confusion.

The book reads both easily and uncontroversially because of the truths it elaborates with quiet honesty and rigour. Its exposition is simple, its creed straightforward – that there are different kinds of depression, that everyone’s experience of mental distress is uniquely theirs in its origins and setting, and that professional kindness and expert unflinching attention matter profoundly. There are different sorts of treatments and some have worked for Gask better than others. That things change – illness and the medical and psychological therapies which help, at different times in life – is a given.

The self and the coordinates of being are tested by depression, but this is a memoir of a life lived with, ultimately, very considerable personal and professional achievement. What is exceptional in this volume is the absolute sanity of its project. It is one of the least mad books on madness imaginable, and it most essentially promotes hopefulness inspite of its tales of real despair and disorientation. It will change the understanding of anyone who has heard the whisper of Eliot’s roar at any point in their lives. Which is, presumably, all of us.

 

 

Lilian Hickey

Consultant in Older Adult Mental Health

Fulbrook Centre

Churchill Hospital

Oxford OX3 7JU.

The Reading Room: When Breath Becomes Air

9 May, 16 | by cquigley

 

Hope, Oncology and Death

Seamus O’Mahony

 

When Breath Becomes Air by Paul Kalanithi. London: The Bodely Head, 2016.

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Paul Kalanithi was nearing the end of his neurosurgical training at Stanford when aged thirty-six, he was diagnosed with stage IV lung cancer. He had never smoked. He was referred to an oncologist specializing in lung cancer. “Emma Hayward” – not her real name – is a central figure in his posthumously-published memoir When Breath Become Air. At their first consultation, Emma refused to discuss survival statistics for stage IV lung cancer, but encouraged Kalanithi to return to work as a surgeon. I shared Kalanithi’s initial reaction: “Go back to work? What is she talking about? Is she delusional?” He argues that for the patient, cancer survival statistics are of little help or succour: “It occurred to me that my relationship with statistics changed as soon as I became one . . . Getting too deeply into statistics is like trying to quench a thirst with salty water. The angst of facing mortality has no remedy in probability.”

But statistics and probability were important for Kalanithi. Examining his options, he reasoned: “Tell me three months, I’d spend time with family. Tell me one year, I’d write a book. Give me ten years, I’d get back to treating diseases.” After an initial encouraging response to chemotherapy, his oncologist is wildly optimistic:

Going over the images with me, Emma said, “I don’t know how long you’ve got, but I will say this: the patient I saw just before you today has been on Tarceva for seven years without a problem. You’ve still got a ways to go before we’re that comfortable with your cancer. But looking at you, thinking about ten years is not crazy.”

As it turned out, Kalanithi survived for twenty-two months following his diagnosis, some distance short of ten years. Encouraged by his oncologist’s optimism, as well as Samuel Beckett’s famous exhortation (“I can’t go on. I’ll go on”), he returned to work as a surgeon: “One part of me exulted at the prospect of ten years. Another part wished she’d said, “Going back to being a neurosurgeon is crazy for you – pick something easier.”” Returning to the operating theatre, he had to lie down during his first case, but “over the next couple of weeks, my strength continued to improve, as did my fluency and technique.” Soon, however, the stark reality of his disease caught up with him:

But the truth was, it was joyless. The visceral pleasure I’d once found in operating was gone, replaced by an iron focus on overcoming the nausea, the pain, the fatigue. Coming home each night, I would scarf down a handful of pain pills, then crawl into bed . . .

Inevitably, as his disease progressed, he knew he could no longer work as a surgeon. When a CT scan showed that his disease was advancing again, “Emma Hayward” managed to put a defiant, Churchillian spin on the situation:

“This is not the end,” she said, a line she must have used a thousand times – after all, did I not use similar speeches to my own patients? – to those seeking impossible answers. “Or even the beginning of the end. This is just the end of the beginning.”

And I felt better.

On the day he was due to attend the graduation ceremony from his residency program, Kalanithi was taken suddenly ill, and ended up in the Intensive Care Unit, where various specialists, including nephrologists, endocrinologists, intensivists and gastroenterologists squabbled over his treatment. Kalanithi refers to this as “the WICOS problem” – Who Is the Captain Of the Ship? Emma – who had been away on holiday – returned, and took over the role of captain. Having pulled her patient through this crisis, she reverted to her relentless optimism: “” You have five good years left,” she said.” Kalanithi, however, saw this wishful, magical thinking for what it was: “She pronounced it, but without the authoritative tone of an oracle, without the confidence of a true believer. She said it, instead, like a plea.” He is remarkably forgiving of this fudging and fibbing, this hesitation to be brave:

There we were, doctor and patient, in a relationship that sometimes carries a magisterial air and other times, like now, was no more, and no less, than two people huddled together, as one faces the abyss. Doctors, it turns out, need hope too.

“Emma Hayward”, like many American oncologists, is part conventional cancer doctor, part shaman. She seems to have been able to simultaneously believe two truths. The conventional cancer doctor part of her surely knew that Kalanithi was, at that point in his illness, unlikely to survive five months, let alone five years, yet the shaman part of her half believed the lie she was telling her patient and herself. Her no doubt well-intentioned exaggeration of Kalanithi’s survival prospects led him to take the ill-advised decision to go back to work as a surgeon, when his remaining time might have been more fruitfully spent with his family and his books.

Kalanithi muses on the nature of hope in terminal illness:

When I talked about hope, then, did I really mean “Leave some room for un-founded desire?” No. . . So did I mean “Leave some room for a statistically improbable but still plausible outcome – a survival just above the measured 95 percent confidence interval.” Is that what hope was? Could we divide the curve into existential sections, from “defeated” to “pessimistic” to “realistic” to “hopeful” to “delusional”? Weren’t the numbers just the numbers? Had we all just given in to the “hope” that every patient was above average?

Atul Gawande wrote how the entire edifice of American cancer treatment is based on the assumption that all patients with advanced cancer are in the small, statistically favoured end of the bell-curve, the medical equivalent, he observed, “of handing out lottery tickets.” Cancer patients are routinely treated on this assumption (or hope), but are not prepared for an outcome – death −  which is overwhelmingly more likely. Optimists would cite the example of the palaeontologist and writer Stephen Jay Gould, and his famous essay, The Median is not the Message. Diagnosed with a rare form of cancer (primary peritoneal mesothelioma), Gould looked up the survival statistics, and found the median survival was just eight months. He noticed, however, that the survival bell-curve was not symmetrical, that it was right-skewed, with a small minority of long-term survivors. Gould reasoned that he might just be in this small minority: “I possessed every one of the characteristics conferring a probability of longer life: I was young; my disease had been recognized in a relatively early stage; I would receive the nation’s best medical treatment.” He was right: he survived for twenty years, dying of an unrelated cancer. I would imagine that this essay is holy scripture for American oncologists.

I am, I confess, an oncology apostate. Cancer treatment seems to offer some patients a toxic combination of false hopes and a bad death. And the oncology community itself acknowledges this. The Lancet Oncology Commission produced a  lengthy report in 2011 called Delivering Affordable Cancer Care in Developed Countries : “The medical profession and the health-care industry have created unrealistic expectations of arrest of disease and death. This set of expectations allows inappropriate application of relatively ineffective therapies . . . cancer treatment is becoming a culture of excess.”

Can we give our patients hope, yet still be honest with them? “Hope” has acquired a very narrow meaning in the cancer setting, namely, an expectation of long-term survival. But for our patients, hope can mean all sorts of things: a reassurance that they will not suffer unbearably, an opportunity to settle affairs and spend time with family, a sure knowledge that their doctor will accompany them on the road as an amicus mortis. Giving hope does not mean creating an atmosphere of histrionic pretence, an atmosphere which inevitably explodes as the end nears. Hope and honesty are not incompatible.

Unfortunately, honesty is heavily disincentivized in modern medicine. A study published in the New England Journal of Medicine in 2012 found that the less patients with advanced cancer knew about their prognosis, the happier they were with their doctors. Nearly all families, and many patients, prefer the Lie. Although he eventually realized that his oncologist was telling him what she thought he wanted to hear, Paul Kalanithi believed in, and acted on, her initial over-optimistic prognosis. If a  man as well-informed and intelligent as Kalanithi could buy the well-intentioned Lie, what hope for the “ordinary” patient?

 

Seamus O’Mahony’s book The Way We Die Now was published on May 5 by Head of Zeus.

 

Who needs their hands? Reflections on being a patient

13 Jun, 11 | by Deborah Kirklin

I have a confession to make: up until a month ago I was a surgical virgin, never having experienced anything more intrusive than the extraction of four unwanted wisdom teeth. Which meant that when I signed up to have operations on both my hands I didn’t have a clue what was in store, but comforted myself with what I’d always told patients: that it was just a small operation, done under local anaesthetic and over in less than twenty minutes, so there was nothing very much to be concerned about.

What I didn’t know was quite how frustrating it is to have your hands out of action. There are irritating things, like not being able to cut up your own food; logistically challenging things, like getting out of a bath; and downright undignified things, of which I’ll say no more, other than acknowledging that access to a bidet can come in handy.

more…

2011 International Symposium on Poetry and Medicine

17 May, 11 | by Ayesha Ahmad

I recently attended the 2nd Annual Hippocrates Poetry and Medicine Symposium, which was held at Warwick Medical School and hosted by Professor Donald Singer and Associate Professor Michael Hulse. During the day, a group of researchers and clinicians from a variety of backgrounds gathered to explore the role of poetry in the discourse of medicine, including renowned poets, Marilyn Hacker and Gwyneth Lewis.

more…

Dr Arati Bhatia describes her own humbling experience with cancer and chemotherapy

10 May, 11 | by Deborah Kirklin

The drainage tube and the negative pressure bag were my constant companions for sixteen days. I was not always respectful of them, even bouncing them around occasionally. I had an intense sense of relief when we were finally parted. They had served their function well. The wound had healed, and there was no collection or infection. Cosmetically, it was a job well done.

Post-mastectomy the strangest sensation was the lack of it. My elbow was numb. I had been unaware of the importance of my elbow to my wellbeing. Now I am reminded every day of what has happened. The operated arm must enter the shirtsleeve or blouse before the normal one. Earlier I had never given much thought to this. Suddenly you are more aware of your own body and its vulnerability. more…

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