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Professional Dilemmas and Experiences

Book Review: True Tales of Organisational Life

6 Feb, 17 | by cquigley

 

True Tales of Organisational Life

Barbara-Anne Wren

Karnac Books Ltd, 2016

ISBN-13: 978-1-78220-189-2

 

Reviewed by Dr Andrew Schuman

 

It’s stories, the psychologist Barbara-Anne Wren reminds us, “that will hold us when nothing else can”. They are humankind’s most effective way of making sense of the world – of organising and giving “a shape to experience”.

The organisation in question, both in the title and at the heart of the book, is the National Health Service (NHS): a gargantuan body employing around two million people. The individuals, working within the service in these straitened times, are facing unprecedented challenges. Relentless waves of financial cuts, along with breathtakingly costly systems of regulation and inspection, have left a workforce more disillusioned and more demoralised than ever before.

Wren’s work as a psychologist and organisational consultant, in a busy London teaching hospital over the past seven years, has been ground-breaking. Rather than seeking the impossible, of  “banishing” emotion and distress at an individual level, her remit has been to “manage meaning and complexity, understand emotional life at both an organisational and individual level, and create spaces in which the unique challenges of healthcare work could be observed and understood.” Some remit.

The strength of Wren’s book lies in her first-hand account of setting up this therapeutic space – in the form of Schwartz Rounds. Originating in America, they consist of a monthly meeting of health professionals, in a forum that is non-hierarchical and deliberately organisation-wide. Their primary focus is on the human dimensions of providing care. Rather than chasing action-points and outcomes, the emphasis in these meetings is on quiet reflection and stillness – storytelling without a means or an end, where “rational and emotional experience have equal permission to emerge”.

At their core is the work of Kenneth Schwartz, a US lawyer, who died of lung cancer in his forties. His own story of diagnosis and treatment was, he writes, “punctuated by moments of exquisite compassion”, [that] “made the unbearable bearable”.  The article he wrote, shortly before he died, serves as a rallying-call:

I cannot emphasize enough how meaningful it was to me when caregivers revealed something about themselves that made a personal connection to my plight. It made me feel much less lonely. The rule-books, I’m sure, frown on such intimate engagement between caregiver and patient. But maybe it’s time to rewrite them…

Our response to his plea must be to support and enable those working in the front-line of the health service – and to encourage and inspire a greater emotional engagement with our patients. As Wren reminds us, psychology’s modus operandi is in “relationship”: “it is dynamic… It works because it moves.”

The protected time and head space of the Schwartz Round give participants permission to open up about the very things that really move them – “what they were proud of, exhausted from”, but also “what saddened and puzzled, infuriated and frightened, humbled and inspired them.”

Two-thirds of the way through the book, we get to its raison d’etre: a collection of seven stories, garnered from the many Schwartz Rounds that Wren has facilitated. These “true tales” (of the title) illustrate the limitless ways in which a particular story is able to “move”, in all senses of the word. They tell a tale, but they show us a greater truth: that stories “will hold us when nothing else can”. With their beginnings, middles and ends, they can bring order and sense – and “sustain us”. Some of the stories arise from clinical issues, others from tensions that can occur between our personal and professional lives; still more concern conflicts at an organisational level.

One of them concerns a “macho” transplant surgeon, who needed to travel to another hospital in order to harvest an organ, before returning gung-ho, aware only of “the happy anticipation of the expectant, hopeful patient” whose life he would be saving – and “ready to demonstrate his skill and authority”. As the successful retrieval surgery came to an end, and the surgical drapes were removed, there was a rustle of paper below the body of the child donating the organs – and a teddy bear tumbled to the floor. The teddy bear was the very first thing the child had been given when he was born; the paper some pages on which family members had imprinted their hands, so that the child would die “in their arms”.

As soon as this was explained to the transplant surgeon, “a ring of steel around his emotions was broken”. By the time of the Schwartz round, the surgeon succeeded (only just) in “gather[ing] up all his energy”, and recounted his experience – including the detail of the teddy bear.

Reading this stopped me short. It also brought to mind the words of the American writer, Maya Angelou: “There is no greater agony than bearing an untold story inside you”. The surgeon’s burden had been made lighter by the telling of his tale, while those listening, bearers of this confessional, could respond only with silence.

Wren unpacks each of the stories she gives us – in this particular case, reflecting on the challenge for clinicians of balancing feelings of sadness and grief with “the business of living”. We need to know, in order to function for the good of all of our patients, when to block each of them out. Both feelings are, of course, essential.

Another tale looks at the case of an abusive patient – but from the perspective of the staff looking after her. As Wren points out, the focus of the Schwartz Round is more on effects than causes: here, the focus was on the impact of the abuse on the individual staff members, and the “reality of what they have to withstand”. Faced with this situation, we can sometimes summon up compassion and creativity; at other times, we’re all too aware of the limits of our compassion. But Wren gets the participants to “question the balance between what is being required of them, what they have left to give, and the containment and support they are being offered” – while appreciating, and exploring, the ways within the group of dealing with such abuse.

The book is not without faults. The editing could have been a little tighter. At times, Wren’s prose tends towards the mystical. Elsewhere, her generalisations can seem weak. “Everyone”, she tells us, “wants to be a psychologist, or is one, or knows one”. Her statement, that patients in hospital “[a]ll have families who want them back” seems, sadly, a tall tale.

But True Tales is good on the practicalities of voicing disharmony in the workplace, and of seeking ways to resolve these conflicts through the timeless alchemy of stories and story telling. “Ever since we were little, the stories have kept the darkness at bay. That and each other will get us through.”

 

Dr Andrew Schuman

Dr Kenyon & Partners,

19 Beaumont St., Oxford, OX1 2NA

 

andrewschuman@doctors.org.uk

 

 

Film Review: The Fugitive Doctor in ‘River’

30 Jun, 16 | by cquigley

 

‘River’, Canada, Laos, 2015, directed by Jamie M. Dagg

Screen_Shot_2016-04-27_at_18.26.59

Released on DVD and digital download on 18th July 2016

Reviewed by Dr Khalid Ali

Doctors and crimes of professional misconduct have been the focus of films such as ‘Coma, USA, 1978’, and ‘Shutter Island, USA, 2010’, while  doctors volunteering in NGOs in troubled zones were the subject of films such as ‘Sleeping sickness Germany, 2011’ and more recently ‘The last face, USA 2016’.

‘River’, a new Canadian film, combines the two themes in its storyline; John Lake ‘Rossif Sutherland’ is an American volunteer doctor in Laos who accidentally kills an Australian citizen in a drunken rage. In his attempt to flee the crime scene, John goes through a harrowing journey across the Mekong River. He tries to get the support of his fellow doctors in the NGO; one of them, Dr Stephanie (Sara Botsford) faces the moral dilemma of whether she should be a whistle-blower and report him to the authorities or should help him escape, while another doctor Douangmany (Douangmany Soliphanh) takes advantage of John’s desperation and uses him as a drug-mule. The loopholes in the legal system between Thailand and Laos give John an opportunity to escape prison. Struggling with his professional role as a doctor who should be saving lives, but an infallible human being at the same time, John approaches the American Embassy in Vientiane for help.

Public interest in doctors’ criminal offences fuelled the media exposure of extreme cases such as the notorious Harold Shipman, and the recent news of Dr Pramela Ganji who was convicted by New Orleans jury in a 34.4 million fraud scheme (1).

The film raises serious questions about the ability of the legal system to exercise ‘equity and fairness’ when operating in a foreign environment such as Laos that is not accountable to regulations set by Western professional bodies. The requirements set by the General Medical Council (GMC) and the British Medical Association (BMA) in England are clear in mandating a ‘code of conduct and practice’ that a doctor should declare a criminal conviction (2, 3).

In addition to its exploration of accountability and violations in healthcare professionals, the film works extremely well as a gripping action thriller winning the best film award at the Academy of Canadian Cinema and Television. Rossif reprises the role of a doctor in turmoil following in his father Donald Sutherland’s footsteps who played a doctor in the cult comedy MASH (USA, 1970).

‘Whistleblowing’ is another thought-provoking theme the film raises; Rodulson argues that reading and appreciating Homer’s the Iliad can support medical students’ understanding of ethical dilemmas (4). ‘River’ achieves a similar feat by portraying a challenging ethical and moral situation where a doctor is ‘trying to do the right thing’.

References

  1. https://www.justice.gov/opa/pr/new-orleans-jury-convicts-company-owner-and-doctor-roles-34-million-fraud-scheme, accessed Wednesday 29th June 2016.
  2. http://www.gmc-uk.org/guidance/ethical_guidance/21184.asp, accessed Wednesday 29th June 2016.
  3. https://www.bma.org.uk/advice/employment/contracts/criminal-record-checks-and-declarations/criminal-convictions-declaration, accessed Wednesday 29th June 2016.
  4. Rodulson V, Marshall R, Bleakley A. Whistleblowing in medicine and in Homer’s Iliad. Med Humanities 2015; 41: 95- 101.

 

Dr Khalid Ali, Screening room editor

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

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.

image1

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.

 

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

The Man in Bed Five by Jack Garnham

28 Jan, 15 | by BMJ

I go to see the man in bed five.

 

He winks at me. Cracked lips separate to reveal an imperfect set of yellow teeth as a wry smile spreads slowly across his face. It comes with an enormous effort. He looks worse; the burden of disease seems to weigh heavier with each passing hour. Sickness has slowly reshaped him, like an obsessive sculptor continually revising his creation. His wife fiddles nervously with her plain wedding band; I feel his decline, but for her each step in the inexorable march of his illness is devastation. She looks at me, and in her eyes I see a deep love and a profound fear. They have been married for forty years. He tells me about his two children. He loves them. His daughter lives in Australia. He has a dog that he takes for walks on the common. He waves a frail arm towards the trees outside the window and tells me that he is looking forward to going home. In our short time together he has granted me open access to his private world, to the countless unique experiences that conspire to create an individual. I will miss him when he is gone, the man in bed five.

 

This once vibrant character is dulled by his sterile surroundings: the bland hospital gown robs him of his humanity; the peeling walls and filthy windows drain him; plastic tubes run into and out of his body. For a moment the hospital is a colossal parasite, nourished by this wasted figure; it breathes in around me and exhales a fetid breath, content at having shelled the man in bed five.

 

I am protected. My fraying badge and cheap stethoscope defend me. The flimsy chart I hold is my shield. I am part of the profession, this most noble profession, and to hurt is weakness, to feel is fragility. He is his disease; he is a hospital number, a set of laboratory results, a trace on a machine, a faint bleep heard from the nursing station. To watch him break I must stand on the other side of the glass. I bid a clinical farewell to the peculiar collection of observations that was once the man in bed five.

 

One day the faint bleep fades. The rush of clinical medicine devours the mourning period; a different set of observations arrives to occupy the bed, and there are pressing results to chase and urgent investigations to order. He remains in my mind as the hours pass. Is it appropriate to grieve? Would it be easier to succumb to indifference? These were the questions asked of me by the man in bed five. Can you balance compassion with detachment? Can you manage the intolerable pain of regular loss? Can you walk the fine line? I bury these thoughts and continue to work.

 

As finals draw closer I find myself more frequently troubled by these questions.

 

I still have no answers.

 

Correspondence: Jack Garnham, Imperial College, London (jack.garnham09@imperial.ac.uk)

Who are we as Doctors? Why an exploration of our significance can lead to better care by Benjamin Janaway

27 Nov, 14 | by BMJ

Recently I lost a patient. A lady in her 60’s whose hand I held for months and who’s passing will stand as a turning point in my career.

Having spent several months working in oncology my view of the role of a doctor has been tested time and time again. Publically observed heuristics of the role of doctors, portrayed subjectively in television and film, novels and novellas, are the hippocratically charged and dutiful healers. Both a font of knowledge and diary of experience, the doctor is seen as a paternalistic figure and eternal purveyor of the omnipotent band aid.

In some cases, within primary care and acute medicine, this may indeed be the case. Early recognition of pathological processes expressed through familiar clinical paradigms allows for rapid reversal of such malady, leading to objective improvement of the patient and maintenance of this social perception. However my experience of secondary and tertiary care of patients with chronic conditions tells a different story.

These patients, when viewed holistically as both the sum of their experience and the filtered view of our own experience, take on significance both within day to day clinical care and the greater role of disease in their lives. Identification with disease, as I have previously mentioned, is a natural and almost unavoidable consequence of the maladaptive nature of the human mind. Our natural insecurities, developed arguably within Jungian theory to inspire adaptive development, can be argued to be destructive when applied to modern day context.

The presence of disease is not just an event in a person’s life, but an event with added context and personally subjective significance. For example, a broken hand means more to a pianist than a footballer. The subjective significance of a change in health status can be explained by the patient’s reliance on past experience and their perceived importance of such a change within the context of their entire lives. The identification of their lives with the change is what the patient sees, but the objective measurement taken by clinicians is usually less in depth.

In terms of cancer, this identification can be both freeing and incarcerating. I have worked with a number of patients, young, old, religious or atheistic with a number of different cancers of varying aggression. Some of these patients were at the start of a journey with an indefinite end, and some were at the end of a journey of indefinite meaning. For some, the end of a long fight, although sad, had changed their lives dramatically and they had lived more in a short time than they had in their lives.

My own grandfather had been diagnosed with multiple myeloma a few years ago and passed away earlier this year. Being both his grandson and a doctor in training was a balancing act, knowing more about the practical and prognostic side of his care and tempering my expectations with that of him and my family. I found this process infinitely difficult and adaptive, learning from my emotional responses better ways to address his own needs and questions.

I would like to say that one of the many lessons I learned from him is that a stoic disposition and optimistic attitude in the face of uncertainty is a great strength. Life goes on between our plans, and our aspirations and reality do not necessarily correlate and it is up to us to meet these changes head on, learn what we can and move on the future. In the treatment of cancer, and the management of my patients, this stoic and optimistic attitude, balanced with an understanding of the patients own identification and experience of disease, is most useful.

So when we consider our own significance within the patient’s experience we must remember the paternalistic view of the omnipotent healer, but also realise that we play only a part in the production of their lives. We are second to the protagonist, and must realise the overall significance of our words on actions not just on the objective clinical state of the patient, but the holistic sphere of their entire disease experience.

More and more I have realised my role as a junior physician and frontline carer is to support the expectations of the patient within a realistic schema. To attempt to best understand their view, but present it to them within a spectrum of experience based on my continued learning and reflection. The omnipotent heuristic can therefore be argued to be of less importance than the archetypal omnibenevolent. As doctors our roles are to first understand the patient and their own judgement of disease significance, and tailor our treatment and interaction in an empathetic and individualised way.

We try to act in the patients best interests, and that means not only to address the physical aspects of their disease but the entire holistic side. Within oncology, this idea takes on extreme importance, as often the societal view of cancer and its ultimate path takes hold in a patients mind. For some it is a challenge, for some freeing, and for others a less positive conclusion. Whatever the view taken, it is up to us as doctors to realise our lines in the script of the patient’s life when this plot twist comes.

For my lady, and for my grandfather, the advent of their disease granted them a new perspective and through long discussion with both I realised the beauty of a new view. Their priorities and expectations changed and they lived without fear. This realisation painted my day to day communication with both and I would hope played a part in making the last years of their lives not just bearable, but an experience they could learn from and leave their mark on the world.

For me, their mark is on my heart, a sign saying ‘Listen and stay open’.

The opinions expressed in this article are those of the author and may not represent those of SDHCT. No patient identifiable information is included.

Correspondence: Dr BM Janaway, Flat 4, Castle Chambers, 147 Union Street, Torquay, Devon TQ1 4BT

The Reading Room

25 Nov, 14 | by cquigley

 

The Bad Doctor

A graphic novel by Ian Williams

Reviewed by Dr Ian Fussell

The Bad Doctor cover final  (1)

 

The Bad Doctor is the debut graphic novel by Ian Williams, himself a pretty good doctor, I reckon, by the insight and humanity shown throughout this book. It was published in June 2014 by Myriad Editions and is a beautifully presented book.

Ian is a physician working in General Practice and GU Medicine in Brighton. He is also the founder of the website graphicmedicine.org for which he coined the term “Graphic Medicine.” Following his training in medicine he studied fine art and achieved a first in an MA in Medical Humanities.

Not unlike the classic graphic novel Maus by Art Spiegelman, The Bad Doctor tells a number of stories simultaneously: that of Iwan James as a GP, Iwan as a sufferer of OCD, and Iwan as a troubled child. We also join Iwan on cycling rides, both alone and with his friend, during which they chew over life’s difficulties. As in Maus, these stories are all related and give the reader an insight into the person Iwan really is. This is what makes the novel stand out and retains the reader’s interest and engagement.

Throughout the novel we are exposed to some of the dilemmas and challenges experienced by a GP living in a small rural community and some of the problems experienced when working closely with partners who you can both hate and fall in love with. Relationships with work colleagues are always complicated and emotionally charged and this novel clearly demonstrates this.

We see young Iwan develop from an angst ridden teenager who loves heavy metal and worries that his behavior is the cause of certain traumatic events, into a man and a doctor who continues to be angst ridden. He fantasises about shooting himself and becomes possibly impaired by obsessive-compulsive disorder, a trait that somewhat perversely may actually benefit patient care.

We witness Iwan struggle with the dilemmas faced by GPs every day, including unpredictable medical emergencies, terminal care, signing shotgun licenses and managing bereavement. He cares about his patients and is naturally empathetic and not afraid to use self-disclosure as a therapeutic tool.

Rather like good poetry, comics and graphic novels can convey difficult and emotive subjects in a way that gives the reader a deeper understanding of the message. Explaining what GPs actually do, to our politicians and the media, by our leaders nearly always inadvertently sounds clichéd and trite and seldom succeeds, despite almost all the population having experienced going to the doctor’s at some point in their lives. Perhaps graphics should be used as a powerful political lever in our profession.

The monochrome drawings are deceptively simple and the text is minimal. This helps make the book very accessible and a pleasure to read. Each chapter starts with an icon that sets the scene for the following chapter.

It would be an oversight not to mention cycling. How many doctors do we all know that cycle or exercise therapeutically, if not obsessively? The benefits of spending time exercising and with friends are so obvious in this novel, that if not already doing so, doctors should be encouraged to start immediately!

Ian Williams Bad Doctor page 70 (1)

I also enjoyed the connection between Iwan as an adult and Iwan as a child. Now with access to social media, music streaming sites and platforms such as You Tube, looking back has never been easier, but this novel adds deeper meaning to this and shows how our young lives and older selves are a continuum rather than distinctly separate entities.

As a 50 year old, a cyclist and a GP living in a rural community who saw Ozzy Osborne on his first tour, it was impossible not to love this book. Ian Williams has possibly written a future classic, which must surely be added to the curriculum of all GP training schemes and might even help our leaders explain what GPs actually do.

 

Ian Williams Bad Doctor town (1)

 

Ian, let’s have some more.

Tell us Dr Smith’s story.

 

 

The Bad Doctor by Ian Williams.

Published by Myriad Editions, 2014.

Sleeping with the Enemy: Arab Doctors Struggling with Personal and Professional Dilemmas

7 Mar, 14 | by Deborah Bowman

A review of “The Attack” and “The Last Man” showing at the “Discover Arab cinema”- British Film Institute- London 2014

“The Attack”, National Film Theatre (‘NFT’) London 23rd and 25th February 2014

“The Last Man”, NFT London 3rd and 8th March

 

London is expanding its cinematic and cultural horizons and the British Film Institute (BFI) is showing the best of Arab cinema in a year-long season https://whatson.bfi.org.uk/Online/default.asp?BOparam::WScontent::loadArticle::permalink=discover-arab-cinema.

 

Two Lebanese films screening at the event explore the current political and social upheaval in the Middle East and its impact on doctors.

 

The first film “The Attack”, directed by Ziad Doueiri is a sensitively-told doctor story mixing several genres: a political thriller, a character study and a romantic love story. Using a compelling narrative, including flash backs, we are introduced to Dr Amin Jaafari (Ali Suliman) a renowned Arab surgeon who is given the highest accolade of a career achievement by the Israeli government – the first time such an honour is bestowed upon a Palestinian surgeon. Socially, he is happily married to a beautiful wife Siham (Reymonde Amsellem). His peaceful life style is shattered when he is called to identify the remains of his wife Siham who was killed in a bomb-suicide attack in Tel Aviv. To make matters worse, the Israeli police suspect that his dead wife was the actual bomber. Traumatised and shocked, Dr Amin is brutally questioned by the Israeli police about the motivations of his wife. He cannot believe that his loving wife could have done such an atrocious deed. In his quest for the truth, Dr Amin travels to the Palestinian city of Nablus to find an explanation, and this brings him in contact with several religious and political figures whose motivations are far from clear.  As a doctor upholding the sanctity of human life and condemning all acts of intentional murder; he realises that he was “sleeping with the enemy” – his own wife.

The second film “The Last Man” directed by Ghassan Salhab” deals with another successful doctor struggling with a different type of enemy: his own psychopathic and criminal tendencies. At the beginning of the film Dr Khalil (Carlos Chahine) is a caring doctor, popular amongst his patients and friends who enjoys diving. The political background of the doctor’s story is closely observed with daily bombs and torture of civilians in Lebanon and Palestine by the Israeli state. Still life goes on in Beirut with loud music blasting away from the clubs that Dr Khalil frequently visits at night. Alongside this volatile external environment, Dr Khalil is slowly changing into a repulsive character who engages in sexual relationships with the mother of one of his patients. The narrative gets more bizarre and disturbing when he becomes a nocturnal creature living off the blood of innocent victims who he preys on from the streets of Beirut. Trying to resist his “vampire” urges for human blood, Dr Khalil still has insight into his own “criminal tendencies”; as a doctor he should be saving lives, not taking them away to feed his nocturnal addiction. On some level, the film can be seen as a study of “obsession, addiction, a moral and psychological decline” of a successful professional who is troubled by his own demons.

Raising several ethical questions, both films suggest that doctors are the products of existing turbulent times and conflict. Ghassan Salhab (director of “The Last Man”) describes his main character Dr Khalil as a “mutant ghost of the city” born out of the social and political disorder in Beirut.

Both films are a timely reminder that the society and media are experiencing a significant shift in their views of the “doctor” as a flawed human being as well as a professional: the “personal and professional boundaries” in doctors’ lives can be blurred resulting in ethical and moral dilemma at a universal manner. Doctors can not remain “oblivious bystanders” in their countries’ changing social and political demography, and if they do they end up losing their identity and closest members of their family such as Dr Jaafari in “The Attack”. Dr Jaafari’s was ambitious to reach the highest academic and professional recognition amongst his peers, but in the process of doing so he alienated himself from his wife and family. His trip back to Nablus proved to him how much he was unwelcomed in his own mother’s house because he made peace with the Israeli establishment.

Recent media attention has focused on doctors in Arab countries such as Egypt, Tunisia and Syria where some doctors collaborated with the oppressive regimes in torturing political opponents. Supporting a dictatorship in such crimes against humanity also violates the basic principles of medicine where a doctor’s primary role is to “never do harm to anyone” as worded in the “Hippocrates Oath”. On a global level, the situation is not all “doom and gloom” as there are several shining examples of altruistic doctors such as those from “Medicins sans Frontieres” who work in disaster areas such as the Philippines. How some doctors choose to be in either group is “food for thought”.

These two films portray doctors as fallible human beings living with their “enemies”. The “enemy” may be external such as a government or family, as in “The attack”, but, more disturbingly, in other situations such as in “The Last Man” the ultimate “enemy” may be a doctor’s own “internal demons”.

Correspondence: Dr Khalid Ali, senior lecturer in Geriatrics at Brighton and Sussex Medical School

Khalid.ali@bsuh.nhs.uk

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